Provider Demographics
NPI:1275562027
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA GREGORY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:400 PARK AVE.
Mailing Address - Street 2:PO BOX 408
Mailing Address - City:GREGORY
Mailing Address - State:SD
Mailing Address - Zip Code:57533-0408
Mailing Address - Country:US
Mailing Address - Phone:605-835-8394
Mailing Address - Fax:605-835-9422
Practice Address - Street 1:110 S LOGAN AVE
Practice Address - Street 2:
Practice Address - City:GREGORY
Practice Address - State:SD
Practice Address - Zip Code:57533-1614
Practice Address - Country:US
Practice Address - Phone:605-835-8394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
275N00000X
SD54875282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0100350Medicaid
SD0159260Medicaid
SD5500350Medicaid
SD431338Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
SD0159260Medicaid