MEDICARE: AVERA QUEEN OF PEACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center	NA	SD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S1639	OTHER	SD	MEDICARE PART B
5	CR0890	OTHER	SD	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	00-00592	OTHER	SD	MEDICA
3	4991003	OTHER	SD	WELLMARK
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619201829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVERA QUEEN OF PEACE

Provider Business Mailing Address
First Line	:	525 N FOSTER ST
Second Line	:
City	:	MITCHELL
State	:	SD
Zip	:	57301-2966
Country	:	US
Telephone Number	:	605-995-2000
Fax Number	:	605-995-2441

Provider Business Practice Location Address
First Line	:	741 S HILL ST
Second Line	:
City	:	SALEM
State	:	SD
Zip	:	57058-8761
Country	:	US
Telephone Number	:	605-425-3038
Fax Number	:	605-425-3039

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DOUGLAS EKEREN
Credential	:
Telephone Number	:	605-668-8322

Provider Enumeration Date	:	09/22/2009
Last Update Date	:	08/20/2020

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Directions to “AVERA QUEEN OF PEACE ” Practice Location

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