Provider Demographics
NPI:1205359031
Name:AVERA QUEEN OF PEACE
Entity type:Organization
Organization Name:AVERA QUEEN OF PEACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-0432
Mailing Address - Country:US
Mailing Address - Phone:605-995-7000
Mailing Address - Fax:
Practice Address - Street 1:525 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2966
Practice Address - Country:US
Practice Address - Phone:605-995-2000
Practice Address - Fax:605-995-5683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-24
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS1639OtherMEDICARE PIN