Provider Demographics
NPI:1174548937
Name:AVERA ST LUKES
Entity type:Organization
Organization Name:AVERA ST LUKES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-5502
Mailing Address - Street 1:1400 10TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1246
Mailing Address - Country:US
Mailing Address - Phone:605-845-7292
Mailing Address - Fax:605-845-7812
Practice Address - Street 1:1400 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1246
Practice Address - Country:US
Practice Address - Phone:605-845-7292
Practice Address - Fax:605-845-7812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Not Answered246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
100351Medicare ID - Type UnspecifiedIDTF