Provider Demographics
NPI:1154324507
Name:AVERA QUEEN OF PEACE
Entity Type:Organization
Organization Name:AVERA QUEEN OF PEACE
Other - Org Name:AVERA QUEEN OF PEACE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EKEREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-668-8322
Mailing Address - Street 1:525 N FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2966
Mailing Address - Country:US
Mailing Address - Phone:605-995-2000
Mailing Address - Fax:605-995-2441
Practice Address - Street 1:525 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2966
Practice Address - Country:US
Practice Address - Phone:605-995-2000
Practice Address - Fax:605-995-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207Q00000X, 367500000X
SD10552282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NR1301XHospitalsGeneral Acute Care HospitalRuralGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCR0890OtherRR MEDICARE
SD0100130Medicaid
SD5500130OtherMEDICAID OUTPATIENT
SD430013Medicare Oscar/Certification
SDS1639Medicare PIN
SD0100130Medicaid