Provider Demographics
NPI:1760560452
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP ELKTON
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 N PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1243
Mailing Address - Country:US
Mailing Address - Phone:605-997-2741
Mailing Address - Fax:605-997-2418
Practice Address - Street 1:203 N ELK ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:SD
Practice Address - Zip Code:57026-2124
Practice Address - Country:US
Practice Address - Phone:605-542-7701
Practice Address - Fax:605-542-7291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN659S2FLOtherBCBS OF MN
WI80484900Medicaid
SD9216572OtherDAKOTCARE
NE10025371500Medicaid
MN126277700Medicaid
SD95027OtherHEALTHPARTNERS
SD106366608OtherDEPARTMENT OF LABOR
SDAH908107523OtherPREFERRED ONE
IA0571919Medicaid
MN659S2FLOtherCC SYSTEMS BLUE PLUS