Basic Information
| Provider Information | |||||||||
| NPI: | 1154531630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
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| OtherOrganizationName: | AVERA MCKENNAN HOSPITAL AND UNIVERSITY HEALTH CENTER - DIABETIC ED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5045 | ||||||||
| Address2: | ATTN: P.F.S. PROV ENROLLMT | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226404 | ||||||||
| FaxNumber: | 6053226499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 S CLIFF AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226404 | ||||||||
| FaxNumber: | 6053226499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6053227916 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 282N00000X | 10563 | SD | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 5590230 | 05 | SD | MEDICAID |