Provider Demographics
NPI:1134324445
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP MCGREEVY 69TH & WESTERN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT OF FINANCE
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 86430
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6430
Mailing Address - Country:US
Mailing Address - Phone:605-322-4900
Mailing Address - Fax:605-322-4910
Practice Address - Street 1:1910 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5612
Practice Address - Country:US
Practice Address - Phone:605-322-5200
Practice Address - Fax:605-322-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD100716Medicare ID - Type Unspecified
SD1202730025Medicare NSC