Provider Demographics
NPI:1659438828
Name:AVERA ST. LUKE'S
Entity Type:Organization
Organization Name:AVERA ST. LUKE'S
Other - Org Name:MARSHALL COUNTY MEDICAL CLINIC AVERA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-5125
Mailing Address - Street 1:PO BOX N
Mailing Address - Street 2:
Mailing Address - City:BRITTON
Mailing Address - State:SD
Mailing Address - Zip Code:57430-0626
Mailing Address - Country:US
Mailing Address - Phone:605-448-5953
Mailing Address - Fax:605-448-2304
Practice Address - Street 1:415 9TH ST
Practice Address - Street 2:
Practice Address - City:BRITTON
Practice Address - State:SD
Practice Address - Zip Code:57430-2274
Practice Address - Country:US
Practice Address - Phone:605-448-5953
Practice Address - Fax:605-448-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9172758OtherDAKOTACARE
ND13974Medicaid
SDS7313Medicare ID - Type UnspecifiedCLINIC PROVIDER NUMBER