Healthcare Provider Details

I. General information

NPI: 1174548937
Provider Name (Legal Business Name): AVERA ST LUKES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 10TH AVE W
MOBRIDGE SD
57601-1246
US

IV. Provider business mailing address

1400 10TH AVE W
MOBRIDGE SD
57601-1246
US

V. Phone/Fax

Practice location:
  • Phone: 605-845-7292
  • Fax: 605-845-7812
Mailing address:
  • Phone: 605-845-7292
  • Fax: 605-845-7812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246R00000X
TaxonomyPathology Technician
License Number
License Number State

VIII. Authorized Official

Name: RON JACOBSON
Title or Position: PRESIDENT
Credential:
Phone: 605-622-5502