Basic Information
Provider Information | |||||||||
NPI: | 1104892892 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA MCKENNAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERA MEDICAL GROUP NEPHROLOGY SIOUX FALLS | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 1315 S. CLIFF AVE. | ||||||||
Address2: | STE. 2000 | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571051058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053225800 | ||||||||
FaxNumber: | 6053225801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2006 | ||||||||
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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 118T5NO | 01 | MN | BCBS | OTHER | 118T5NO | 01 | MN | BLUE PLUS | OTHER | 0550814 | 05 | IA |   | MEDICAID | 12903 | 05 | ND |   | MEDICAID | 9191250 | 01 | SD | DAKOTACARE | OTHER | 031013001 | 01 | MN | PRIMEWEST | OTHER | 210830500 | 05 | MN |   | MEDICAID | 0008493 | 01 | SD | BCBS | OTHER | 370624200 | 01 | SD | DEPT OF LABOR | OTHER | 81741 | 01 | SD | HEALTHPARTNERS | OTHER |