Provider Demographics
NPI:1629052451
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA LEE MABEE OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/SVP
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7818
Mailing Address - Street 1:PO BOX 84632
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-4632
Mailing Address - Country:US
Mailing Address - Phone:605-322-5260
Mailing Address - Fax:605-322-5265
Practice Address - Street 1:1910 W 69TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5612
Practice Address - Country:US
Practice Address - Phone:605-322-5260
Practice Address - Fax:605-322-5265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2481207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
22232OtherSIOUX VALLEY HEALTH PLAN
228834OtherMIDLANDS CHOICE
SD6200390Medicaid
0009398OtherWALLMARK
22232OtherSIOUX VALLEY HEALTH PLAN
228834OtherMIDLANDS CHOICE