Basic Information
| Provider Information | |||||||||
| NPI: | 1396945267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP LIVER DISEASE SIOUX FALLS | ||||||||
| 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: | 1315 S. CLIFF AVE. | ||||||||
| Address2: | STE. 1200 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228535 | ||||||||
| FaxNumber: | 6053228536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6053228000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0008X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology |
ID Information
| ID | Type | State | Issuer | Description | 9250205 | 01 | SD | DAKOTACARE | OTHER | 164563 | 01 | SD | HEALTHPARTNERS | OTHER | 8G749AV | 01 | MN | BCBS | OTHER | 8G749AV | 01 | MN | BLUE PLUS | OTHER | 1396945267 | 05 | IA | MEDICAID |