1154350064 NPI number — AVERA MCKENNAN

Table of content: (NPI 1154350064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154350064 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:
1154350064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5045
Provider Second Line Business Mailing Address:
CBO PROVENRLMT PALM PLACE
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's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 NORTH IOWA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELL RAPIDS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57022-1231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-428-5431
Provider Business Practice Location Address Fax Number:
605-428-3906
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  50754 , 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: 102355100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5500450 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1026470 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0040666 . This is a "SD BLUE CROSS CRNA GROUP" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 3F59HDE . This is a "MN BLUECROSS BS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 43-0082 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 543140 . This is a "ARAZ" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0100450 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0584227 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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