Basic Information
| Provider Information | |||||||||
| NPI: | 1952727463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MARSHALL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERA@HOME SOUTHWEST MINNESOTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562581934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075329661 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 S BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562581934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075377070 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2014 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | V.P. OF FINANCE/IS | ||||||||
| AuthorizedOfficialTelephone: | 5075379150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | MN | Y | Agencies | Hospice Care, Community Based |
No ID Information.