Provider Demographics
NPI:1124464128
Name:AVERA ST. MARY'S
Entity type:Organization
Organization Name:AVERA ST. MARY'S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-224-3144
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:CBO PALM PLACE PRV ENRLMT
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-6428
Mailing Address - Fax:605-224-8339
Practice Address - Street 1:801 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3323
Practice Address - Country:US
Practice Address - Phone:605-224-3100
Practice Address - Fax:605-224-8339
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA ST. MARY'S HOSPITAL CHILD ASSESSMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-16
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5405080Medicaid