Basic Information
| Provider Information | |||||||||
| NPI: | 1649461369 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVERA MCKENNAN | ||||||||
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| OtherOrganizationName: | AVERA NEUROSURGERY - DANIEL G. TYNAN, M.D. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86370 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571186370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 E 21ST ST | ||||||||
| Address2: | STE 600 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224800 | ||||||||
| FaxNumber: | 6053224801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 03/30/2010 | ||||||||
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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 | 207T00000X | 4653 | SD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9251035 | 01 | SD | DAKOTACARE | OTHER | 10025595900 | 05 | NE | MEDICAID | 4992604 | 01 | SD | BLUE CROSS/SD | OTHER | 6I362AV | 01 | MN | BLUE PLUS | OTHER |