Basic Information
| Provider Information | |||||||||
| NPI: | 1962724831 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MARSHALL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP OPTOMETRY REDWOOD FALLS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562581934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075329661 | ||||||||
| FaxNumber: | 5076375715 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | REDWOOD FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562831168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076375715 | ||||||||
| FaxNumber: | 5076375715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2010 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE AND I.S. | ||||||||
| AuthorizedOfficialTelephone: | 5075379150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.