Provider Demographics
NPI:1083679625
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP MILLER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:300 W 5TH ST
Mailing Address - Street 2:PO BOX 287
Mailing Address - City:MILLER
Mailing Address - State:SD
Mailing Address - Zip Code:57362-1238
Mailing Address - Country:US
Mailing Address - Phone:605-853-0158
Mailing Address - Fax:605-853-3885
Practice Address - Street 1:300 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MILLER
Practice Address - State:SD
Practice Address - Zip Code:57362-1238
Practice Address - Country:US
Practice Address - Phone:605-853-0158
Practice Address - Fax:605-853-3885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS100880Medicare PIN