Provider Demographics
NPI:1982057246
Name:CITY OF BROOKINGS
Entity Type:Organization
Organization Name:CITY OF BROOKINGS
Other - Org Name:AVERA MEDICAL GROUP SPECIALTY CARE BROOKINGS A DEPARTMENT OF BROOKINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MERKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-696-8010
Mailing Address - Street 1:310 22ND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 22ND AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006
Practice Address - Country:US
Practice Address - Phone:605-696-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF BROOKINGS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-21
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD430008Medicare PIN