Provider Demographics
NPI:1104892892
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:PO BOX 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:1301 S CLIFF AVE STE 4400
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1005
Practice Address - Country:US
Practice Address - Phone:605-322-5800
Practice Address - Fax:605-322-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN210830500Medicaid
IA0550814Medicaid
SD0008493OtherBCBS
MN031013001OtherPRIMEWEST
MN118T5NOOtherBCBS
ND12903Medicaid
SD370624200OtherDEPT OF LABOR
SD81741OtherHEALTHPARTNERS
MN118T5NOOtherBLUE PLUS
SD9191250OtherDAKOTACARE
MN210830500Medicaid
MNC03144Medicare PIN
MN118T5NOOtherBCBS
ND12903Medicaid
MN118T5NOOtherBLUE PLUS