Provider Demographics
NPI:1558624668
Name:AVERA ST. LUKE'S
Entity Type:Organization
Organization Name:AVERA ST. LUKE'S
Other - Org Name:AVERA MEDICAL GROUP IPSWICH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:FORKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-5125
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:605-622-2857
Mailing Address - Fax:605-622-2859
Practice Address - Street 1:501 BLOEMENDAAL DRIVE
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:SD
Practice Address - Zip Code:57451
Practice Address - Country:US
Practice Address - Phone:605-622-2857
Practice Address - Fax:605-622-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS101808Medicare PIN