Basic Information
| Provider Information | |||||||||
| NPI: | 1295747608 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AVERA FLANDREAU HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5045 ATTN PRVENROLMT PALM PLACE BLDG | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226428 | ||||||||
| FaxNumber: | 6053226499 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 N PRAIRIE ST | ||||||||
| Address2: | |||||||||
| City: | FLANDREAU | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570281243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059972433 | ||||||||
| FaxNumber: | 6059973611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6053227915 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 10540 | SD | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 80484900 | 05 | WI | MEDICAID | 00B2896 | 05 | NM | MEDICAID | 1778HFL | 01 | MN | MN BLUE CROSS PROV# | OTHER | 202619 | 05 | AZ | MEDICAID | 5500412 | 05 | SD | MEDICAID | 01592 | 05 | ND | MEDICAID | 1295747608 | 05 | WY | MEDICAID | 0100412 | 05 | SD | MEDICAID | 10025183900 | 05 | NE | MEDICAID | 1295747608 | 05 | MI | MEDICAID | 192355200 | 05 | MN | MEDICAID | 81310 | 01 | SD | SD BLUE CROSS HOSP PROV# | OTHER | 0587261 | 05 | IA | MEDICAID | 4103188 | 05 | MT | MEDICAID |