1891718136 NPI number — AVERA MCKENNAN

Table of content: (NPI 1891718136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891718136 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:
1891718136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2020
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:
ATTN: P.F.S.
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:
605-322-7187
Provider Business Mailing Address Fax Number:
605-322-7183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 S CLIFF AVE
Provider Second Line Business Practice Location Address:
REGIONAL LAB
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-7187
Provider Business Practice Location Address Fax Number:
605-322-7183
Provider Enumeration Date:
07/26/2006

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: 291U00000X , with the licence number:  43D0658878 , 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: 4995742 . This is a "BLUE CROSS OF SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 604999 . This is a "ARAZ" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5580610 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1034593 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 165L6AV . This is a "BLUE CROSS OF MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: F230764 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0569285 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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