Provider Demographics
NPI:1548290539
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
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:PO BOX 108
Mailing Address - Street 2:308 MAIN ST
Mailing Address - City:COLOME
Mailing Address - State:SD
Mailing Address - Zip Code:57528-0108
Mailing Address - Country:US
Mailing Address - Phone:605-842-1186
Mailing Address - Fax:
Practice Address - Street 1:308 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLOME
Practice Address - State:SD
Practice Address - Zip Code:57528-0108
Practice Address - Country:US
Practice Address - Phone:605-842-1186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0000028OtherWELLMARK BC/BS
NE=========49Medicaid
SDS28Medicare PIN
SD0000028OtherWELLMARK BC/BS
NE=========49Medicaid