MEDICARE: AVERA ST. LUKE'S

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	2086S0122X	Plastic and Reconstructive Surgery Physician	10525	SD

General Provider Information

NPI Number	:	1619273927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVERA ST. LUKE'S

Provider Business Mailing Address
First Line	:	PO BOX 1460
Second Line	:
City	:	ABERDEEN
State	:	SD
Zip	:	57402-1460
Country	:	US
Telephone Number	:	605-725-5030
Fax Number	:	605-725-5028

Provider Business Practice Location Address
First Line	:	4141 31ST AVE S STE 105
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-8778
Country	:	US
Telephone Number	:	605-725-5030
Fax Number	:	605-725-5028

Authorized Official
Title or Position	:	CEO
Name	:	RON L JACOBSON
Credential	:
Telephone Number	:	605-622-5125

Provider Enumeration Date	:	02/03/2011
Last Update Date	:	06/30/2011

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