Provider Demographics
NPI:1538135447
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP HEMATOLOGY, TRANSPLANT & CELLULAR THERAPY SIOUX FA
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 1:1000 E. 23RD ST.
Practice Address - Street 2:STE. 200
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2122
Practice Address - Country:US
Practice Address - Phone:605-322-3035
Practice Address - Fax:605-322-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0007442OtherBCBS
IA0573931Medicaid
SD71664OtherHEALTHPARTNERS
MN306918400Medicaid
MN68B91LEOtherBCBS
SD9174731OtherDAKOTACARE
MN68B91LEOtherBLUE PLUS
SD370624200OtherDEPT OF LABOR
MN92411422911OtherPRIMEWEST
NE=========42Medicaid
NE=========42Medicaid
IA0573931Medicaid