1770690398 NPI number — AVERA MCKENNAN

Table of content: (NPI 1770690398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770690398 NPI number — AVERA MCKENNAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA MCKENNAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVERA FLANDREAU HOSPITAL SWINGBED
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770690398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5045 ATTN PRVENROLMT PALM PLACE BLDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-6428
Provider Business Mailing Address Fax Number:
605-322-6499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 N PRAIRIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLANDREAU
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57028-1243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-997-2433
Provider Business Practice Location Address Fax Number:
605-997-3611
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PLACE
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
605-322-7903

Provider Taxonomy Codes

  • Taxonomy code: 275N00000X , with the licence number:  10540 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0159732 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Z310 . This is a "SD BLUE CROSS SWGBD PROV#" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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