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General NPI Number Information
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NPI Number | 1114594868
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Entity Type | Organization
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Legal Business Name | AVERA MCKENNAN
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Dates
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Enumeration Date | 06/09/2021
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Last Update Date | 06/09/2021
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Provider Practice Location Address
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Address Line | 301 FLYNN DR
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City | MILBANK
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State | SD
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Zip | 57252-1508
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Country | US
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Telephone | 605-432-4587
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Fax | 605-432-4580
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Provider Business Mailing Address
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Address Line | PO BOX 5045 PFS PROV ENRLMT PALM PLACE
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City | SIOUX FALLS
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State | SD
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Zip | 57117-5045
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DAVID WILLIAM FLICEK
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Credential |
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Telephone | 605-322-7915
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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