Basic Information
| Provider Information | |||||||||
| NPI: | 1255307450 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP FUNCTIONAL MEDICINE | ||||||||
| 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: | 911 E 20TH ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053223455 | ||||||||
| FaxNumber: | 6053223456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6053228000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 370624200 | 01 | SD | DEPT OF LABOR | OTHER | 67B25MI | 01 | MN | BLUE PLUS | OTHER | 67B25MI | 01 | MN | BCBS | OTHER | 9177384 | 01 | SD | DAKOTACARE | OTHER | 0007280 | 01 | SD | BCBS | OTHER | 10025120100 | 05 | NE | MEDICAID | 74474 | 01 | SD | HEALTHPARTNERS | OTHER | 0748939 | 05 | IA | MEDICAID | 775790500 | 05 | MN | MEDICAID |