Provider Demographics
NPI:1902886567
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MEDICAL GROUP SPENCER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-6375
Mailing Address - Street 1:116 E 11TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4364
Mailing Address - Country:US
Mailing Address - Phone:712-264-3500
Mailing Address - Fax:712-264-3535
Practice Address - Street 1:116 E 11TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4364
Practice Address - Country:US
Practice Address - Phone:712-264-3500
Practice Address - Fax:712-264-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207Q00000X, 363A00000X, 363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0252791Medicaid
IA0252791Medicaid
IA1202730014Medicare NSC