Provider Demographics
NPI:1932105046
Name:AVERA QUEEN OF PEACE
Entity Type:Organization
Organization Name:AVERA QUEEN OF PEACE
Other - Org Name:AVERA MEDICAL GROUP CORSICA
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 1:265 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CORSICA
Practice Address - State:SD
Practice Address - Zip Code:57328
Practice Address - Country:US
Practice Address - Phone:605-946-5411
Practice Address - Fax:605-946-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDN/A261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCR0890OtherMEDICARE RR
SD5306742Medicaid
SD5306743Medicaid
SD0000018OtherWELLMARK
SDA-87545OtherMULTIPLAN
SD00-00435OtherMEDICA
SDS7742Medicare PIN
SD5306742Medicaid
SD5306743Medicaid