Provider Demographics
NPI:1053557967
Name:AVERA QUEEN OF PEACE
Entity type:Organization
Organization Name:AVERA QUEEN OF PEACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-995-2251
Mailing Address - Street 1:525 N FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2966
Mailing Address - Country:US
Mailing Address - Phone:605-995-2000
Mailing Address - Fax:605-995-2441
Practice Address - Street 1:115 SECOND ST SE
Practice Address - Street 2:
Practice Address - City:DE SMET
Practice Address - State:SD
Practice Address - Zip Code:57231-0463
Practice Address - Country:US
Practice Address - Phone:605-854-3834
Practice Address - Fax:605-854-3878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0232SD363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS1639Medicare PIN