Provider Demographics
NPI:1588978423
Name:AVERA MEDICAL GROUP WEBSTER
Entity type:Organization
Organization Name:AVERA MEDICAL GROUP WEBSTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-622-5890
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 1:401 E HIGHWAY 12 STE 2
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:SD
Practice Address - Zip Code:57274-1148
Practice Address - Country:US
Practice Address - Phone:605-345-2222
Practice Address - Fax:605-345-2223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA ST LUKES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-03
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS101808Medicare PIN