NPIMap

Organization Active NPI

Avera St. Luke's

Doing business as Avera Medical Group Physical Medicine Aberdeen

  • Physical Medicine & Rehabilitation Physician
  • Aberdeen, SD
National Provider Identifier
1093759177
Registry record updated Jul 15, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Medicine & Rehabilitation PhysicianTaxonomy code 208100000X
License
10525 Issued in SD
Legal business name
AVERA ST. LUKE'S
Doing business as
Avera Medical Group Physical Medicine Aberdeen
Practice address
201 S Lloyd St
Suite E202
Aberdeen, SD 57401-4552
Phone
(605) 622-2898
Fax
(605) 622-2897
NPI assigned
Jun 16, 2006
Last updated
Jul 15, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 15, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tess Moeller
Title
VP
Phone
(605) 622-2807

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Medicine & Rehabilitation Physician 208100000X 10525 SD Primary

Addresses

Primary practice location

201 S Lloyd St
Suite E202
Aberdeen, SD 57401-4552

Mailing address

PO Box 1460
Aberdeen, SD 57402-1460
Phone (605) 622-2898

Other identifiers 2

IdentifierTypeStateIssuer
13479MedicaidND
9263552OtherDAKOTACARE

Other names 1

  • Avera Medical Group Physical Medicine Aberdeen Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040120000912 SD Part B Supplier - Clinic/Group Practice 6406764927 Receives reassigned benefits from 271 practitioners
39 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Aberdeen, SD; Waubay, SD; Redfield, SD; Mobridge, SD; Groton, SD; Faulkton, SD; Britton, SD

Other NPIs on the same Medicare enrollment 39

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 39

National Provider Directory

National Provider Directory

Locations

201 S Lloyd St
Ste E202
Aberdeen, SD 57401
Phone (605) 622-2605

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1657843200000",
    "number": "1093759177",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1460",
            "city": "ABERDEEN",
            "state": "SD",
            "postal_code": "574021460",
            "telephone_number": "605-622-2898",
            "fax_number": "605-622-2897"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 S LLOYD ST",
            "address_2": "SUITE E202",
            "city": "ABERDEEN",
            "state": "SD",
            "postal_code": "574014552",
            "telephone_number": "605-622-2898",
            "fax_number": "605-622-2897"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AVERA ST. LUKE'S",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-16",
        "last_updated": "2022-07-15",
        "certification_date": "2022-07-15",
        "status": "A",
        "authorized_official_last_name": "MOELLER",
        "authorized_official_first_name": "TESS",
        "authorized_official_title_or_position": "VP",
        "authorized_official_telephone_number": "605-622-2807"
    },
    "taxonomies": [
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "SD",
            "license": "10525",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "13479",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAKOTACARE",
            "identifier": "9263552",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avera Medical Group Physical Medicine Aberdeen",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Avera Medical Group Physical Medicine Aberdeen",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Aberdeen, SD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.