Basic Information
Provider Information | |||||||||
NPI: | 1215951629 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA MCKENNAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERA MCKENNAN HOSPITAL AND UNIVERSITY HEALTH CENTER - REHAB UNIT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5045 | ||||||||
Address2: | ATTN: P.F.S. | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053226400 | ||||||||
FaxNumber: | 6053226499 | ||||||||
Practice Location | |||||||||
Address1: | 1325 S CLIFF AVE | ||||||||
Address2: | REHABILITATION UNIT | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571051007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053226400 | ||||||||
FaxNumber: | 6053226499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2006 | ||||||||
LastUpdateDate: | 01/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLICEK | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 6053227916 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 10563 | SD | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 475747501 | 05 | MN |   | MEDICAID | 8T016 | 01 | SD | BLUE CROSS OF SD | OTHER | 0230260 | 05 | SD |   | MEDICAID |