Provider Demographics
NPI:1467752899
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:CORE ORTHOPEDICS AVERA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-6375
Mailing Address - Street 1:2908 E. 26TH ST.
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-4034
Mailing Address - Country:US
Mailing Address - Phone:605-336-2638
Mailing Address - Fax:605-334-3500
Practice Address - Street 1:2908 E. 26TH ST.
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-4034
Practice Address - Country:US
Practice Address - Phone:605-336-2638
Practice Address - Fax:605-334-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1202730029OtherSD MEDICARE DME
MNC05723Medicare PIN
SDS40252Medicare PIN
IAI13114Medicare PIN