Basic Information
| Provider Information | |||||||||
| NPI: | 1154506384 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA UNIVERSITY PSYCHIATRY ASSOCIATES-MARSHALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86370 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571186370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104 E COLLEGE DR | ||||||||
| Address2: | STE. B | ||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562584270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073372923 | ||||||||
| FaxNumber: | 5073372926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2008 | ||||||||
| LastUpdateDate: | 03/31/2010 | ||||||||
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| AuthorizedOfficialLastName: | NORTON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6053226375 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 81G87AV | 01 | MN | BLUE CROSS | OTHER | 86467 | 01 | SD | HEALTHPARTNERS | OTHER | 81G87AV | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | CG9797 | 01 | SD | RR MEDICARE | OTHER | 996458400 | 05 | MN | MEDICAID |