Provider Demographics
NPI:1013980598
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP UNIVERSITY PSYCHIATRY ASSOCIATES SIOUX FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-8000
Mailing Address - Street 1:PO BOX 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:4400 W 69TH ST STE 1500
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8171
Practice Address - Country:US
Practice Address - Phone:605-322-5700
Practice Address - Fax:605-322-5704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0561456Medicaid
MN50M77UNOtherBLUE PLUS/CC SYSTEMS
MN81G87AVOtherBCBS MN
IA22591OtherBCBS IA
SD86467OtherHEALTHPARTNERS
SD0040470OtherBCBS
MN040121002OtherPRIMEWEST
MN996458400Medicaid
MN81G97AVOtherBLUE PLUS/CCS
NE=========52Medicaid
SD86467OtherHEALTHPARTNERS
SDCG9797Medicare PIN
MN81G97AVOtherBLUE PLUS/CCS
IAI9306Medicare PIN