Provider Demographics
NPI:1114246576
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MCKENNAN OUTPATIENT THERAPY MCGREEVY MAIN
Other - Org Type:Other Name
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-6375
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-6400
Mailing Address - Fax:605-322-6499
Practice Address - Street 1:1200 S 7TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0900
Practice Address - Country:US
Practice Address - Phone:605-782-8307
Practice Address - Fax:605-782-8322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10563261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS30016Medicare PIN