Basic Information
| Provider Information | |||||||||
| NPI: | 1285701870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP MCGREEVY BRANDON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86430 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571186430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224900 | ||||||||
| FaxNumber: | 6053224910 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 E HOLLY BLVD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570051426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055823853 | ||||||||
| FaxNumber: | 6055823855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 05/10/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NORTON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6053227818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0716829 | 05 | IA | MEDICAID |