Basic Information
| Provider Information | |||||||||
| NPI: | 1619187192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OUTPATIENT PHYSICAL THERAPY - O.I. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E 21ST ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226400 | ||||||||
| FaxNumber: | 6053226499 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E 21ST ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226400 | ||||||||
| FaxNumber: | 6053226499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 03/12/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NORTON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6053226375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 10563 | SD | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 5550060 | 05 | SD | MEDICAID |