Provider Demographics
NPI:1386834661
Name:PIONEER MEMORIAL HOSPITAL & HEALTH SERVICES
Entity Type:Organization
Organization Name:PIONEER MEMORIAL HOSPITAL & HEALTH SERVICES
Other - Org Name:VIBORG MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POKORNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-326-5161
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:VIBORG
Mailing Address - State:SD
Mailing Address - Zip Code:57070-0337
Mailing Address - Country:US
Mailing Address - Phone:605-326-5201
Mailing Address - Fax:605-326-5196
Practice Address - Street 1:103 W PIONEER
Practice Address - Street 2:
Practice Address - City:VIBORG
Practice Address - State:SD
Practice Address - Zip Code:57070-0337
Practice Address - Country:US
Practice Address - Phone:605-326-5201
Practice Address - Fax:605-326-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0000085OtherSD BLUE SHIELD
SDS85Medicare PIN
SDCS0588Medicare PIN