Basic Information
| Provider Information | |||||||||
| NPI: | 1417246901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVERA MCKENNAN | ||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP OPHTHALMOLOGY 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 911 E 20TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053223790 | ||||||||
| FaxNumber: | 6053223791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6053227915 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.