Provider Demographics
NPI:1417246901
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP OPHTHALMOLOGY SIOUX FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP OF FINANCE
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:605-322-7915
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:
Practice Address - Street 1:911 E 20TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1043
Practice Address - Country:US
Practice Address - Phone:605-322-3790
Practice Address - Fax:605-322-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS40252Medicare PIN