Healthcare Provider Details

I. General information

NPI: 1053827634
Provider Name (Legal Business Name): AVERA QUEEN OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

IV. Provider business mailing address

PO BOX 432
MITCHELL SD
57301-0432
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-6337
  • Fax: 605-995-5779
Mailing address:
  • Phone: 605-995-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierS1639
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerMEDICARE

VIII. Authorized Official

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