Basic Information
Provider Information
NPI: 1073585949
EntityType: 2
ReplacementNPI:  
OrganizationName: AVERA MCKENNAN
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: AVERA MEDICAL GROUP NEONATOLOGY SIOUX FALLS
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 86370
Address2:  
City: SIOUX FALLS
State: SD
PostalCode: 571186370
CountryCode: US
TelephoneNumber: 6053227510
FaxNumber: 6053226475
Practice Location
Address1: 1325 S. CLIFF AVE.
Address2:  
City: SIOUX FALLS
State: SD
PostalCode: 571051007
CountryCode: US
TelephoneNumber: 6053224425
FaxNumber: 6053224499
Other Information
ProviderEnumerationDate: 02/06/2006
LastUpdateDate: 10/24/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FLICEK
AuthorizedOfficialFirstName: DAVID
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO/PRESIDENT
AuthorizedOfficialTelephone: 6053228000
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2080N0001X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine

ID Information
IDTypeStateIssuerDescription
6159801SDHEALTHPARTNERSOTHER
055536705IA MEDICAID
06577860005MN MEDICAID
37062420001SDDEPT OF LABOROTHER
670134005SD MEDICAID
670150005SD MEDICAID
670179005SD MEDICAID
7F824MA01MNBLUE PLUSOTHER
499972301SDBCBSOTHER
670109005SD MEDICAID


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