Provider Demographics
NPI:1558337899
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP PEDIATRIC SPECIALISTS SIOUX FALLS
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 1:1417 S. CLIFF AVE.
Practice Address - Street 2:STE. 010
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1014
Practice Address - Country:US
Practice Address - Phone:605-322-3666
Practice Address - Fax:605-322-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN000080878OtherPRIMEWEST
SD0006729OtherBCBS
MN3D887KUOtherBLUE PLUS
SD370624200OtherDEPT OF LABOR
MN200806800Medicaid
MN250R5PEOtherBCBS WORTHINGTON
MN3D887KUOtherBCBS
IA0248534Medicaid
SD9169058OtherDAKOTACARE
SD65740OtherHEALTHPARTNERS
NE=========39Medicaid
MN000080878OtherPRIMEWEST
SD9169058OtherDAKOTACARE
SD370624200OtherDEPT OF LABOR
NE=========39Medicaid