Provider Demographics
NPI:1700905650
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7818
Mailing Address - Street 1:4928 N CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-0563
Mailing Address - Country:US
Mailing Address - Phone:605-332-5100
Mailing Address - Fax:605-322-5101
Practice Address - Street 1:4928 N CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-0563
Practice Address - Country:US
Practice Address - Phone:605-332-5100
Practice Address - Fax:605-322-5101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA MCKENNAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD53352083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33732OtherIA MEDICAL LICENSE
SD5335OtherSD MEDICAL LICENSE