1760560452 NPI number — AVERA MCKENNAN

Table of content: SENECA MARIE CARDIFF DO (NPI 1538802368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760560452 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:
Provider Other Organization Name Type Code:
6
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:
1760560452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 N PRAIRIE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLANDREAU
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57028-1243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-997-2741
Provider Business Mailing Address Fax Number:
605-997-2418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 N ELK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKTON
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57026-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-542-7701
Provider Business Practice Location Address Fax Number:
605-542-7291
Provider Enumeration Date:
11/01/2006

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 VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
605-322-6375

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 659S2FL . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 80484900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9216572 . This is a "DAKOTCARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 10025371500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 126277700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95027 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 106366608 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: AH908107523 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0571919 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 659S2FL . This is a "CC SYSTEMS BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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