Provider Demographics
NPI:1093759177
Name:AVERA ST. LUKE'S
Entity Type:Organization
Organization Name:AVERA ST. LUKE'S
Other - Org Name:AVERA MEDICAL GROUP PHYSICAL MEDICINE ABERDEEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-2898
Mailing Address - Fax:605-622-2897
Practice Address - Street 1:201 S LLOYD ST
Practice Address - Street 2:SUITE E202
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4552
Practice Address - Country:US
Practice Address - Phone:605-622-2898
Practice Address - Fax:605-622-2897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10525208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9263552OtherDAKOTACARE
ND13479Medicaid
SDS101808Medicare PIN
SDS42355Medicare PIN