Provider Demographics
NPI:1023003969
Name:HEART HOSPITAL OF SOUTH DAKOTA LLC
Entity Type:Organization
Organization Name:HEART HOSPITAL OF SOUTH DAKOTA LLC
Other - Org Name:AVERA HEART HOSPITAL OF SOUTH DAKOTA LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-977-7009
Mailing Address - Street 1:4500 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8148
Mailing Address - Country:US
Mailing Address - Phone:605-977-7000
Mailing Address - Fax:605-977-7001
Practice Address - Street 1:4500 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8148
Practice Address - Country:US
Practice Address - Phone:605-977-7000
Practice Address - Fax:605-977-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD41953282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0542191Medicaid
SD5500250Medicaid
MN320460000Medicaid
SD80095OtherWELLMARK
SD0100250Medicaid
SD5500250Medicaid
SD5500250Medicaid
MN320460000Medicaid
NE=========00Medicaid