NPIMap

Organization Active NPI

Avera St. Luke's

Doing business as Avera St. Luke's FastCare Shopko

  • Family Medicine Physician
  • Aberdeen, SD
National Provider Identifier
1871728501
Registry record updated Jun 29, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
10525 Issued in SD
Legal business name
AVERA ST. LUKE'S
Doing business as
Avera St. Luke's FastCare Shopko
Practice address
500 N Highway 281
Aberdeen, SD 57401-1821
Phone
(605) 622-2856
Fax
(605) 622-5963
NPI assigned
May 26, 2009
Last updated
Jun 29, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 29, 2011

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

Authorized official

Name
Mr. Ron L Jacobson
Title
President & Ceo
Phone
(605) 622-5125

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 10525 SD Primary

Addresses

Primary practice location

500 N Highway 281
Aberdeen, SD 57401-1821

Mailing address

PO Box 1460
Aberdeen, SD 57402-1460
Phone (605) 622-2856

Other names 1

  • Avera St. Luke's FastCare Shopko 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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1243296000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1309305600000",
    "number": "1871728501",
    "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": "605-622-2856",
            "fax_number": "605-622-5963"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 N HIGHWAY 281",
            "city": "ABERDEEN",
            "state": "SD",
            "postal_code": "574011821",
            "telephone_number": "605-622-2856",
            "fax_number": "605-622-5963"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AVERA ST. LUKE'S",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-26",
        "last_updated": "2011-06-29",
        "status": "A",
        "authorized_official_last_name": "JACOBSON",
        "authorized_official_first_name": "RON",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "605-622-5125",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SD",
            "license": "10525",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avera St. Luke's FastCare Shopko",
            "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 Jun 29, 2011; 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.