Basic Information
| Provider Information | |||||||||
| NPI: | 1992712921 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA QUEEN OF PEACE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AVERA WESKOTA MEM MED CNTR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 609 1ST ST NE | ||||||||
| Address2: | |||||||||
| City: | WESSINGTON SPRINGS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573822136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055391201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 609 1ST ST NE | ||||||||
| Address2: | |||||||||
| City: | WESSINGTON SPRINGS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573822136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055391201 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EKEREN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6056688321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336I0012X | 2000994 | SD | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4353859 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |