Provider Demographics
NPI:1497847446
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP BIG STONE CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
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 1:451 MAIN ST
Mailing Address - Street 2:PO BOX 145
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216
Mailing Address - Country:US
Mailing Address - Phone:605-862-7999
Mailing Address - Fax:605-862-7998
Practice Address - Street 1:451 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIG STONE CITY
Practice Address - State:SD
Practice Address - Zip Code:57216
Practice Address - Country:US
Practice Address - Phone:605-862-7999
Practice Address - Fax:605-862-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty