Provider Demographics
NPI:1194873851
Name:AVERA COLMAN MEDICAL CLINIC
Entity type:Organization
Organization Name:AVERA COLMAN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-428-5446
Mailing Address - Street 1:109 N. MAIN
Mailing Address - Street 2:
Mailing Address - City:COLMAN
Mailing Address - State:SD
Mailing Address - Zip Code:57017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 N. MAIN
Practice Address - Street 2:
Practice Address - City:COLMAN
Practice Address - State:SD
Practice Address - Zip Code:57017
Practice Address - Country:US
Practice Address - Phone:0
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4884207Q00000X
SD5054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5610960Medicaid
SD5611290Medicaid
SDH46420Medicare UPIN
SDH70197Medicare UPIN
SD8142Medicare ID - Type Unspecified
SD40598Medicare ID - Type Unspecified