Provider Demographics
NPI:1528017662
Name:PIONEER MEMORIAL HOSPITAL &HEALTH SERVICES
Entity Type:Organization
Organization Name:PIONEER MEMORIAL HOSPITAL &HEALTH SERVICES
Other - Org Name:CENTERVILLE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
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 368
Mailing Address - Street 2:
Mailing Address - City:VIBORG
Mailing Address - State:SD
Mailing Address - Zip Code:57070-0368
Mailing Address - Country:US
Mailing Address - Phone:605-326-5161
Mailing Address - Fax:605-326-5734
Practice Address - Street 1:512 BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:SD
Practice Address - Zip Code:57014-0070
Practice Address - Country:US
Practice Address - Phone:605-563-2411
Practice Address - Fax:605-563-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4993935OtherBLUE CROSS BLUE SHIELD
SD5340280Medicaid
SD4993935OtherBLUE CROSS BLUE SHIELD
SD433428Medicare Oscar/Certification