Healthcare Provider Details

I. General information

NPI: 1386793776
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S. SHERMAN
COLTON SD
57018
US

IV. Provider business mailing address

PO BOX 9 300 S. SHERMAN
COLTON SD
57018
US

V. Phone/Fax

Practice location:
  • Phone: 605-446-3233
  • Fax:
Mailing address:
  • Phone: 605-446-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5214
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3570
License Number StateSD

VIII. Authorized Official

Name: JULIE N. NORTON
Title or Position: SENIOR VICE PRESIDENT FINANCE
Credential:
Phone: 605-322-6375