MEDICARE: AVERA MCKENNAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VM0101X	Maternal & Fetal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	361ROPE	OTHER	MN	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	370624200	OTHER	SD	DEPT OF LABOR
6	95736	OTHER	SD	HEALTHPARTNERS
7	361R1WA	OTHER	MN	BLUE PLUS
8	9216740	OTHER	SD	DAKOTACARE
9	924114229808	OTHER	SD	PRIMEWEST
10	4994376	OTHER	SD	BCBS

General Provider Information

NPI Number	:	1205808748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVERA MCKENNAN

Provider Business Mailing Address
First Line	:	PO BOX 86370
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57118-6370
Country	:	US
Telephone Number	:	605-322-7510
Fax Number	:	605-322-6475

Provider Business Practice Location Address
First Line	:	1417 S. CLIFF AVE.
Second Line	:	STE. 100
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-1063
Country	:	US
Telephone Number	:	605-322-8937
Fax Number	:	605-322-8938

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DAVID FLICEK
Credential	:
Telephone Number	:	605-322-8000

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	10/24/2018

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Directions to “AVERA MCKENNAN ” Practice Location

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