Provider Demographics
NPI:1003869892
Name:AVERA TYLER
Entity Type:Organization
Organization Name:AVERA TYLER
Other - Org Name:AVERA MEDICAL GROUP LAKE BENTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-537-9160
Mailing Address - Street 1:109 E BENTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE BENTON
Mailing Address - State:MN
Mailing Address - Zip Code:56149-1309
Mailing Address - Country:US
Mailing Address - Phone:507-368-4323
Mailing Address - Fax:507-368-4546
Practice Address - Street 1:109 E BENTON ST
Practice Address - Street 2:
Practice Address - City:LAKE BENTON
Practice Address - State:MN
Practice Address - Zip Code:56149-1309
Practice Address - Country:US
Practice Address - Phone:507-368-4323
Practice Address - Fax:507-368-4546
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA MEDICAL GROUP TYLER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9732144Medicaid
MN5T014TYOtherBLUE CROSS BLUE SHIELD
MNC02403Medicare PIN