Provider Demographics
NPI:1063432573
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-6375
Mailing Address - Street 1:210 KASAN AVE
Mailing Address - Street 2:
Mailing Address - City:VOLGA
Mailing Address - State:SD
Mailing Address - Zip Code:57071
Mailing Address - Country:US
Mailing Address - Phone:605-627-5701
Mailing Address - Fax:605-627-5990
Practice Address - Street 1:210 KASAN AVE
Practice Address - Street 2:
Practice Address - City:VOLGA
Practice Address - State:SD
Practice Address - Zip Code:57071
Practice Address - Country:US
Practice Address - Phone:605-627-5701
Practice Address - Fax:605-627-5990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA MCKENNAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-20
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD84363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7300750Medicaid
SD7300750Medicaid