Provider Demographics
NPI:1700062213
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP WORTHINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN GROUW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-372-2921
Mailing Address - Street 1:1216 RYANS RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1722
Mailing Address - Country:US
Mailing Address - Phone:507-372-2921
Mailing Address - Fax:507-372-5789
Practice Address - Street 1:1216 RYANS RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1722
Practice Address - Country:US
Practice Address - Phone:507-372-2921
Practice Address - Fax:507-372-5789
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA MCKENNAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-15
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN690009299OtherRAILROAD MEDICARE
MN48941WOOtherBCBS
MN951015000Medicaid
MN48941WOOtherBCBS