Provider Demographics
NPI:1295747608
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:PO BOX 5045 ATTN PRVENROLMT PALM PLACE BLDG
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-6428
Mailing Address - Fax:605-322-6499
Practice Address - Street 1:214 N PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1243
Practice Address - Country:US
Practice Address - Phone:605-997-2433
Practice Address - Fax:605-997-3611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10540282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0587261Medicaid
WY1295747608Medicaid
WI80484900Medicaid
SD5500412Medicaid
SD0100412Medicaid
NE10025183900Medicaid
MN1778HFLOtherMN BLUE CROSS PROV#
MN192355200Medicaid
ND01592Medicaid
MT4103188Medicaid
NM00B2896Medicaid
AZ202619Medicaid
MI1295747608Medicaid
SD81310OtherSD BLUE CROSS HOSP PROV#
ND01592Medicaid
NE10025183900Medicaid
MI1295747608Medicaid