Provider Demographics
NPI:1174671242
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP GARRETSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT 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 1:908 4TH ST.
Mailing Address - Street 2:
Mailing Address - City:GARRETSON
Mailing Address - State:SD
Mailing Address - Zip Code:57030
Mailing Address - Country:US
Mailing Address - Phone:605-594-3431
Mailing Address - Fax:
Practice Address - Street 1:980 4TH STREET
Practice Address - Street 2:
Practice Address - City:GARRETSON
Practice Address - State:SD
Practice Address - Zip Code:57030-0250
Practice Address - Country:US
Practice Address - Phone:605-594-3431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3579207Q00000X
SD4884207Q00000X
SD5054207Q00000X
SD5214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5611292Medicaid
SD5610962Medicaid
SD5609088Medicaid
SD5611473Medicaid
SD5611292Medicaid
SD41363Medicare ID - Type Unspecified
SD5611473Medicaid
SD3421Medicare ID - Type Unspecified
SD8142Medicare ID - Type Unspecified
SDE72988Medicare UPIN
SD5610962Medicaid
SDH46420Medicare UPIN