Organization
WAGNER COMMUNITY MEMORIAL HOSPITAL
Active
Other names
Wagner Community Clinic Avera
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. BERNADETTE R KOUPAL (BUS. OFFICE MANAGER)
(605) 384-3611
Entity
Organization
Contact information
Practice address
513 3RD ST SW, WAGNER, SD 57380-9675
(605) 384-3418
(605) 384-5240
Mailing address
PO BOX 280, WAGNER, SD 57380-0280
(605) 384-3418
(605) 384-5240
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
10571
SD
363A00000X
Physician Assistant
10571
SD
363LF0000X
Family Nurse Practitioner
10571
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1008854
—
SD
01
—
S5877
MEDICARE GROUP
SD
Enumeration date
03/21/2007
Last updated
03/07/2017
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