Basic Information
Provider Information | |||||||||
NPI: | 1538135447 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA MCKENNAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERA MEDICAL GROUP HEMATOLOGY, TRANSPLANT & CELLULAR THERAPY SIOUX FA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 86370 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571186370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053227510 | ||||||||
FaxNumber: | 6053226475 | ||||||||
Practice Location | |||||||||
Address1: | 1000 E. 23RD ST. | ||||||||
Address2: | STE. 200 | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571052122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053223035 | ||||||||
FaxNumber: | 6053223036 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2006 | ||||||||
LastUpdateDate: | 01/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLICEK | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6053228000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 0007442 | 01 | SD | BCBS | OTHER | 0573931 | 05 | IA |   | MEDICAID | 71664 | 01 | SD | HEALTHPARTNERS | OTHER | 306918400 | 05 | MN |   | MEDICAID | 68B91LE | 01 | MN | BCBS | OTHER | 9174731 | 01 | SD | DAKOTACARE | OTHER | 68B91LE | 01 | MN | BLUE PLUS | OTHER | 370624200 | 01 | SD | DEPT OF LABOR | OTHER | 92411422911 | 01 | MN | PRIMEWEST | OTHER |