Provider Demographics
NPI:1699985267
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:RONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:ATTN: P.F.S.
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-6428
Mailing Address - Fax:605-322-6499
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:STE ED
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1007
Practice Address - Country:US
Practice Address - Phone:605-322-2000
Practice Address - Fax:605-322-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10563207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5800080Medicaid
IA0900993Medicaid