Provider Demographics
NPI:1396711016
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7903
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 1:1600 S HIGHLINE AVE STE 310
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-1007
Practice Address - Country:US
Practice Address - Phone:605-322-7600
Practice Address - Fax:605-322-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN321J0DAOtherBCBS
SD370624200OtherDEPT OF LABOR
SD370624200OtherDEPT OF LABOR
SDS40454Medicare PIN