Provider Demographics
NPI:1710995626
Name:AVERA ST MARYS
Entity Type:Organization
Organization Name:AVERA ST MARYS
Other - Org Name:AVERA ST MARYS HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-224-3127
Mailing Address - Street 1:801 E SIOUX AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-224-3100
Mailing Address - Fax:605-224-8339
Practice Address - Street 1:801 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-224-3100
Practice Address - Fax:605-224-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD437046251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD87046OtherBLUE CROSS PROVIDER #
SD0170030Medicaid
SD437046Medicare ID - Type UnspecifiedMEDICARE PROVIDER #