Basic Information
| Provider Information | |||||||||
| NPI: | 1386610004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP PULMONARY AND SLEEP MEDICINE SIOUX FALLS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 S. MINNESOTA AVE. | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571053762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 S. CLIFF AVE. | ||||||||
| Address2: | STE. 601 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226930 | ||||||||
| FaxNumber: | 6053226931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6053228000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 92411422905 | 01 | MN | PRIME WEST | OTHER | 0555169 | 05 | IA | MEDICAID | 286T1PU | 01 | MN | BLUE PLUS | OTHER | 9202238 | 01 | SD | DAKOTACARE | OTHER | 84208 | 01 | SD | HEALTHPARTNERS | OTHER | 984617400 | 05 | MN | MEDICAID | 0040252 | 01 | SD | BCBS SD | OTHER | 286T1PU | 01 | MN | BCBS MN | OTHER | 370624200 | 01 | SD | DEPT OF LABOR | OTHER |