Provider Demographics
NPI:1912936535
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP BROOKINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-6375
Mailing Address - Street 1:400 22ND AVE.
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2497
Mailing Address - Country:US
Mailing Address - Phone:605-697-9500
Mailing Address - Fax:605-697-6939
Practice Address - Street 1:400 22ND AVE.
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2497
Practice Address - Country:US
Practice Address - Phone:605-697-9500
Practice Address - Fax:605-697-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1202730018Medicare NSC
SDS42279Medicare PIN