Basic Information
| Provider Information | |||||||||
| NPI: | 1538527106 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA DIALYSIS WAGNER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5045 | ||||||||
| Address2: | PFS PROV ENRLLMT | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226404 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 W SD HIGHWAY 46 | ||||||||
| Address2: | |||||||||
| City: | WAGNER | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573809304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053844980 | ||||||||
| FaxNumber: | 6053844990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2016 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6053227915 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 10563 | SD | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 1538527106 | 01 | SD | WELLMARK BCBS | OTHER |