Provider Demographics
NPI:1427003946
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP WAUBAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
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:605-322-7916
Mailing Address - Street 1:80 N MAIN ST
Mailing Address - Street 2:PO BOX 215
Mailing Address - City:WAUBAY
Mailing Address - State:SD
Mailing Address - Zip Code:57273
Mailing Address - Country:US
Mailing Address - Phone:605-947-4322
Mailing Address - Fax:605-947-3423
Practice Address - Street 1:80 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUBAY
Practice Address - State:SD
Practice Address - Zip Code:57273
Practice Address - Country:US
Practice Address - Phone:605-947-4322
Practice Address - Fax:605-947-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
SD0317363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5300800Medicaid
43D0974942OtherCLIA #
SD5300800Medicaid