Provider Demographics
NPI:1245275189
Name:AVERA ST. LUKE'S
Entity type:Organization
Organization Name:AVERA ST. LUKE'S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:FORKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-5125
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-4050
Mailing Address - Fax:605-622-4049
Practice Address - Street 1:201 S LLOYD ST
Practice Address - Street 2:E205
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4552
Practice Address - Country:US
Practice Address - Phone:605-622-4050
Practice Address - Fax:605-622-4049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10525208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9237225OtherDAKOTACARE
ND14000Medicaid
SD4993532OtherWELLMARK BC/BS OF SD
SD9237225OtherDAKOTACARE