Provider Demographics
NPI:1588677892
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7915
Mailing Address - Street 1:901 E VIRGIL AVE
Mailing Address - Street 2:
Mailing Address - City:MILBANK
Mailing Address - State:SD
Mailing Address - Zip Code:57252-2124
Mailing Address - Country:US
Mailing Address - Phone:605-432-4538
Mailing Address - Fax:605-432-5412
Practice Address - Street 1:305 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:REVILLO
Practice Address - State:SD
Practice Address - Zip Code:57259-0006
Practice Address - Country:US
Practice Address - Phone:605-623-4695
Practice Address - Fax:605-623-4318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4996359OtherSD BLUE CROSS-REVILLO P#
MN246933200Medicaid
SD9204609OtherDAKOTACARE REVILLO PROV#
MN228L6REOtherMN BLUE CROSS-REVILLO P#
SD5800490Medicaid
MN246933200Medicaid