Provider Demographics
NPI:1255408944
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT OF FIANCE
Authorized Official - Prefix:
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:PO BOX 86430
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6430
Mailing Address - Country:US
Mailing Address - Phone:605-322-4900
Mailing Address - Fax:605-322-4901
Practice Address - Street 1:3400 S SOUTHEASTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-7184
Practice Address - Country:US
Practice Address - Phone:605-371-1866
Practice Address - Fax:605-371-0918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDDE2294Medicare ID - Type UnspecifiedRR MEDICARE
IA0716829Medicare ID - Type UnspecifiedIA MEDICAID GRP NUMBER
SDS100716Medicare ID - Type Unspecified
SD1202730023Medicare NSC