Basic Information
| Provider Information | |||||||||
| NPI: | 1821686932 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVERA MCKENNAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86370 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571186370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226408 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1417 S CLIFF AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053223440 | ||||||||
| FaxNumber: | 6053223654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6053227915 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
No ID Information.