Provider Demographics
NPI:1255307450
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP FUNCTIONAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-8000
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 1:911 E 20TH ST
Practice Address - Street 2:STE 200
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1042
Practice Address - Country:US
Practice Address - Phone:605-322-3455
Practice Address - Fax:605-322-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD370624200OtherDEPT OF LABOR
MN67B25MIOtherBLUE PLUS
MN67B25MIOtherBCBS
SD9177384OtherDAKOTACARE
SD0007280OtherBCBS
NE10025120100Medicaid
SD74474OtherHEALTHPARTNERS
IA0748939Medicaid
MN775790500Medicaid
SDS7280Medicare PIN
MN775790500Medicaid