Provider Demographics
NPI:1609848175
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA KANNAN CLINIC
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 1:2400 S MINNESOTA AVE.
Mailing Address - Street 2:STE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-3762
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:911 E 20TH ST
Practice Address - Street 2:STE. 403
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1042
Practice Address - Country:US
Practice Address - Phone:605-322-7516
Practice Address - Fax:605-322-7519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7419Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER