Provider Demographics
NPI:1619948007
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP FLANDREAU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MRS
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 1:212 NORTH PRAIRIE STREET
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1296
Mailing Address - Country:US
Mailing Address - Phone:605-997-2471
Mailing Address - Fax:605-997-2418
Practice Address - Street 1:212 NORTH PRAIRIE STREET
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1296
Practice Address - Country:US
Practice Address - Phone:605-997-2471
Practice Address - Fax:605-997-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025371500Medicaid
SD106366608OtherDEPARTMENT OF LABOR
MN126277700Medicaid
SD9216572OtherDAKOTACARE
NE10025485500OtherRHC MEDICAID NE
SD5340320Medicaid
MN659S2FLOtherBCBS OF MN
SD4995978OtherBCBS OF SOUTH DAKOTA
SD95027OtherHEALTHPARTNERS
IA0571919Medicaid
MN659S2FLOtherCC SYSTEMS BLUE PLUS
WI80484900Medicaid
SD9216572OtherDAKOTACARE
IA0571919Medicaid