1427003946 NPI number — AVERA MCKENNAN

Table of content: (NPI 1427003946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427003946 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 WAUBAY
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:
1427003946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 N MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 215
Provider Business Mailing Address City Name:
WAUBAY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-947-4322
Provider Business Mailing Address Fax Number:
605-947-3423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUBAY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-947-4322
Provider Business Practice Location Address Fax Number:
605-947-3423
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLICEK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
605-322-7916

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 0317 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5300800 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43D0974942 . This is a "CLIA #" identifier . This identifiers is of the category "OTHER".




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