Healthcare Provider Details

I. General information

NPI: 1205808748
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 S. CLIFF AVE. STE. 100
SIOUX FALLS SD
57105-1063
US

IV. Provider business mailing address

PO BOX 86370
SIOUX FALLS SD
57118-6370
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-8937
  • Fax: 605-322-8938
Mailing address:
  • Phone: 605-322-7510
  • Fax: 605-322-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID FLICEK
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-322-8000