Provider Demographics
NPI:1154346625
Name:AVERA ST. LUKE'S
Entity type:Organization
Organization Name:AVERA ST. LUKE'S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-2807
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-2857
Mailing Address - Fax:605-622-2859
Practice Address - Street 1:4401 MAIN ST
Practice Address - Street 2:
Practice Address - City:SELBY
Practice Address - State:SD
Practice Address - Zip Code:57472
Practice Address - Country:US
Practice Address - Phone:605-649-9999
Practice Address - Fax:605-946-9987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6153OtherWELLMARK BC/BS OF SD
SD6153OtherWELLMARK BC/BS OF SD
SDDA9201Medicare PIN