Provider Demographics
NPI:1649223439
Name:AVERA TYLER
Entity Type:Organization
Organization Name:AVERA TYLER
Other - Org Name:AVERA MEDICAL GROUP TYLER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-537-9160
Mailing Address - Street 1:240 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-1201
Mailing Address - Country:US
Mailing Address - Phone:507-247-5921
Mailing Address - Fax:507-247-5184
Practice Address - Street 1:240 WILLOW ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-0240
Practice Address - Country:US
Practice Address - Phone:507-247-5921
Practice Address - Fax:507-247-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC07385OtherPART B MC
MN5T014TYOtherBLUE CROSS BLUE SHIELD
MN97635800Medicaid
MN97635800Medicaid
MN243413Medicare Oscar/Certification
C07385Medicare Oscar/Certification