Provider Demographics
NPI:1649577297
Name:AVERA QUEEN OF PEACE
Entity Type:Organization
Organization Name:AVERA QUEEN OF PEACE
Other - Org Name:AVERA GRASSLAND DIAGNOSTICS
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 1:1900 GRASSLAND DR.
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-6205
Practice Address - Country:US
Practice Address - Phone:605-995-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD63654261QR0200X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1649577297Medicaid
SDS104930Medicare PIN
SD430013Medicare Oscar/Certification