1295747608 NPI number — AVERA MCKENNAN

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295747608 NPI number — AVERA MCKENNAN

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 Other Organization Name:

AVERA FLANDREAU HOSPITAL

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:

1295747608

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

10/04/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

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 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:

08/13/2006

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

• Taxonomy code: 282NC0060X , with the licence number:  10540 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0587261 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1295747608 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
• Identifier: 80484900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 5500412 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: 0100412 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: 10025183900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 1778HFL . This is a "MN BLUE CROSS PROV#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 192355200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 01592 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
• Identifier: 4103188 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
• Identifier: 00B2896 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
• Identifier: 202619 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
• Identifier: 1295747608 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 81310 . This is a "SD BLUE CROSS HOSP PROV#" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".