1700062213 NPI number — AVERA MCKENNAN

Table of content: MRS. CECILIA J KIM MS, LMFT (NPI 1659584167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700062213 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 WORTHINGTON
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:
1700062213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1216 RYANS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORTHINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56187-1722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-372-2921
Provider Business Mailing Address Fax Number:
507-372-5789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1216 RYANS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORTHINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56187-1722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-372-2921
Provider Business Practice Location Address Fax Number:
507-372-5789
Provider Enumeration Date:
01/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VAN GROUW
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
507-372-2921

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 690009299 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 48941WO . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 951015000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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