Basic Information
| Provider Information | |||||||||
| NPI: | 1417929100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP CERTIFIED NURSE MIDWIFERY 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: | 1417 S. CLIFF AVE. | ||||||||
| Address2: | STE. 400A | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228877 | ||||||||
| FaxNumber: | 6053228941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 02/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | NORTON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6053226375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 10025071600 | 05 | NE | MEDICAID | 0006113 | 01 | SD | BCBS | OTHER | 370624200 | 01 | SD | DEPT OF LABOR | OTHER | 50F30HA | 01 | MN | BLUE PLUS | OTHER | 0745737 | 05 | IA | MEDICAID | 70415 | 01 | SD | HEALTHPARTNERS | OTHER | 9240193 | 01 | SD | DAKOTACARE | OTHER |