Basic Information
Provider Information | |||||||||
NPI: | 1700146396 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA MCKENNAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERA MCKENNAN OUTPATIENT THERAPY EAST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5045 | ||||||||
Address2: | ATTN: PT FINANCIAL SERVICES PROV ENROLLMENT | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053226400 | ||||||||
FaxNumber: | 6053226499 | ||||||||
Practice Location | |||||||||
Address1: | 1035 SOUTH HIGHLINE PL | ||||||||
Address2: | STE #4 | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 57110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053222959 | ||||||||
FaxNumber: | 6053222926 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2012 | ||||||||
LastUpdateDate: | 05/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NORTON | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | SVP/CFO | ||||||||
AuthorizedOfficialTelephone: | 6053227818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 10563 | SD | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.