Avera Queen of Peace
Organization Active NPI Specialist · Mitchell, SD
NPI 1053548982 · NPPES record last updated Aug 20, 2020
Key facts
- NPI
- 1053548982
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Specialist 174400000X
- Legal business name
- AVERA QUEEN OF PEACE
- Practice address
- 525 N Foster St
Mitchell, SD 57301-2966 - Phone
- (605) 995-2000
- Fax
- (605) 995-2441
- NPI assigned
- Jun 18, 2009
- Organization subpart
- No
Authorized official
- Name
- Douglas Ekeren
- Title
- President/Ceo
- Phone
- (605) 668-8322
Other NPIs on the same Medicare enrollment 31
Practitioners 11
-
Rachel Dykstra, CNP
-
Matthew P Finke, M.D.
-
Karley Fischer, PA-C
-
Joel L Grow, MD
-
Susan Kay Olson, CNP/PAC
-
Suzanne Linnea Woodward, M.D.
-
Latonia Jovita Moncur, M.D.
-
Daniel Shih, M.D.
-
Christopher Vogl, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in SD
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031229000301 | SD | Part B Supplier - Clinic/Group Practice | 9335050806 |
Receives reassigned benefits from 252 practitioners 31 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Mitchell, SD; Parkston, SD; Pierre, SD; Platte, SD; Sioux Falls, SD; Wagner, SD; Wessington Springs, SD; Yankton, SD… |
National Provider Directory
Locations
801 3rd St SW
De Smet, SD 57231
Phone (605) 854-3455
1308 W 15th Ave
Mitchell, SD 57301
625 N Foster St
Ste 107
Mitchell, SD 57301
Phone (605) 995-6350
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist |
174400000X | Yes |
Addresses
Primary practice location
525 N Foster St
Mitchell, SD 57301-2966
Mailing address
525 N Foster St
Mitchell, SD 57301-2966
Phone (605) 995-2000
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5500130 | Medicaid | SD |
Other names
- Avera Medical Group Occupational Medicine
Other providers in Mitchell, SD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 20, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.