Provider Demographics
NPI:1154506384
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA UNIVERSITY PSYCHIATRY ASSOCIATES-MARSHALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP 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 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:1104 E COLLEGE DR
Practice Address - Street 2:STE. B
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-4270
Practice Address - Country:US
Practice Address - Phone:507-337-2923
Practice Address - Fax:507-337-2926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN81G87AVOtherBLUE CROSS
SD86467OtherHEALTHPARTNERS
MN81G87AVOtherCC SYSTEMS/ BLUE PLUS
SDCG9797OtherRR MEDICARE
MN996458400Medicaid
MN996458400Medicaid