Basic Information
Provider Information | |||||||||
NPI: | 1932105046 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA QUEEN OF PEACE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERA MEDICAL GROUP CORSICA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 525 N FOSTER ST | ||||||||
Address2: |   | ||||||||
City: | MITCHELL | ||||||||
State: | SD | ||||||||
PostalCode: | 573012966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6059952000 | ||||||||
FaxNumber: | 6059952441 | ||||||||
Practice Location | |||||||||
Address1: | 265 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | CORSICA | ||||||||
State: | SD | ||||||||
PostalCode: | 57328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6059465411 | ||||||||
FaxNumber: | 6059465206 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2005 | ||||||||
LastUpdateDate: | 08/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EKEREN | ||||||||
AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 6056688322 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N/A | SD | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | CR0890 | 01 | SD | MEDICARE RR | OTHER | 5306742 | 05 | SD |   | MEDICAID | 5306743 | 05 | SD |   | MEDICAID | 0000018 | 01 | SD | WELLMARK | OTHER | A-87545 | 01 | SD | MULTIPLAN | OTHER | 00-00435 | 01 | SD | MEDICA | OTHER |