Healthcare Provider Details

I. General information

NPI: 1063654648
Provider Name (Legal Business Name): AVERA ST MARYS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E SIOUX AVE
PIERRE SD
57501-3323
US

IV. Provider business mailing address

PO BOX 5045
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-3100
  • Fax: 605-224-8339
Mailing address:
  • Phone: 605-322-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10662
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier85034
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerBCBS
# 2
Identifier0150360
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: MIKEL HOLLAND
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-224-3144