Provider Demographics
NPI:1003867029
Name:AVERA ST LUKES
Entity Type:Organization
Organization Name:AVERA ST LUKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC VP
Authorized Official - Prefix:
Authorized Official - First Name:TESS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-2807
Mailing Address - Street 1:305 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4527
Mailing Address - Country:US
Mailing Address - Phone:605-622-5000
Mailing Address - Fax:605-622-5255
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4527
Practice Address - Country:US
Practice Address - Phone:605-622-5000
Practice Address - Fax:605-622-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10525273R00000X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2381Medicaid
SD0230330Medicaid
SD0230332Medicaid
SD=========004OtherCHAMPUS HOSPITAL PSYCH UN
SD43S014Medicare Oscar/Certification