1851491690 NPI number — AVERA MCKENNAN

Table of content: (NPI 1851491690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851491690 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 MEDICAL GROUP WINDOM
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:
1851491690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 E 21ST STREET
Provider Second Line Business Mailing Address:
PO BOX5045
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:
605-322-6375
Provider Business Mailing Address Fax Number:
605-322-6363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 HOSPITAL DR., STE. 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDOM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56101-1766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-831-1703
Provider Business Practice Location Address Fax Number:
507-831-5668
Provider Enumeration Date:
09/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FLICEK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
605-322-7915

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C18643 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 433903700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".