Healthcare Provider Details

I. General information

NPI: 1861740151
Provider Name (Legal Business Name): AVERA QUEEN OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2012
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 E 5TH AVE
MITCHELL SD
57301-2917
US

IV. Provider business mailing address

1115 E 5TH AVE
MITCHELL SD
57301-2917
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-5553
  • Fax:
Mailing address:
  • Phone: 605-996-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS EKEREN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 605-668-8322