Provider Demographics
NPI:1336111962
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP WOMENS HEALTH SPECIALISTS 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 1:1417 S. CLIFF AVE.
Practice Address - Street 2:STE. 401
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1064
Practice Address - Country:US
Practice Address - Phone:605-322-8920
Practice Address - Fax:605-322-8919
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
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD040115001OtherPRIMEWEST
SD370624200OtherDEPT OF LABOR
SD0007994OtherBCBS
IA0548537Medicaid
IA33583OtherBC/IA
IA04235OtherBC/IA
MN48D59OBOtherBCBS
MN48D59OBOtherBLUE PLUS
IA33582OtherBC/IA
IA70000OtherBC/IA
MN194898900Medicaid
IA33581OtherBC/IA
SD77716OtherHEALTHPARTNERS
SD9177835OtherDAKOTACARE
MN194898900Medicaid
SDS7994Medicare PIN
SD040115001OtherPRIMEWEST
MNC03392Medicare PIN