Provider Demographics
NPI:1851491690
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP WINDOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7915
Mailing Address - Street 1:800 E 21ST STREET
Mailing Address - Street 2:PO BOX5045
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-6375
Mailing Address - Fax:605-322-6363
Practice Address - Street 1:2020 HOSPITAL DR., STE. 2
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1766
Practice Address - Country:US
Practice Address - Phone:507-831-1703
Practice Address - Fax:507-831-5668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA MCKENNAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C18643OtherRAILROAD MEDICARE
MN433903700Medicaid
MN433903700Medicaid
MN1202730008Medicare NSC