Provider Demographics
NPI:1831504711
Name:AVERA ST LUKES
Entity type:Organization
Organization Name:AVERA ST LUKES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BJERKNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-5125
Mailing Address - Street 1:PO BOX 860674
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0001
Mailing Address - Country:US
Mailing Address - Phone:605-229-1367
Mailing Address - Fax:605-229-1002
Practice Address - Street 1:310 S PENN ST STE 201
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4553
Practice Address - Country:US
Practice Address - Phone:605-229-1367
Practice Address - Fax:605-229-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10525261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD2008682Medicaid
ND1468051Medicaid