Provider Demographics
NPI:1346216074
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP DERMATOLOGY SIOUX FALLS
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 1:6701 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2591
Practice Address - Country:US
Practice Address - Phone:605-322-6960
Practice Address - Fax:605-322-6961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN115182700Medicaid
SD370624200OtherDEPT OF LABOR
MN396S9MIOtherBLUE PLUS
SD9202239OtherDAKOTACARE
MN040122003OtherPRIMEWEST
SD83986OtherHEALTHPARTNERS
IA0554733Medicaid
SD0040219OtherBCBS
MN396S9MIOtherBCBS
SD0040219OtherBCBS
MN396S9MIOtherBCBS
NE=========43Medicaid
MN040122003OtherPRIMEWEST