1538527106 NPI number — AVERA MCKENNAN

Table of content: (NPI 1538527106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538527106 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:
1538527106
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:
PFS PROV ENRLLMT
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:
605-322-6404
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 W SD HIGHWAY 46
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAGNER
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57380-9304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-384-4980
Provider Business Practice Location Address Fax Number:
605-384-4990
Provider Enumeration Date:
02/10/2016

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: 261QE0700X , with the licence number:  10563 , 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: 1538527106 . This is a "WELLMARK BCBS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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