1093908501 NPI number — AVERA MCKENNAN

Table of content: (NPI 1093908501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093908501 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 NEUROSURGERY - MARK W. FOX, M.D., FACS
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:
1093908501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86370
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:
57118-6370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 E 21ST ST
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-4825
Provider Business Practice Location Address Fax Number:
605-322-4826
Provider Enumeration Date:
08/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NORTON
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
SENIOR VP OF FINANCE
Authorized Official Telephone Number:
605-322-6375

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  4319 , 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: 10025562500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 167004 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 46L93AV . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9251034 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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