=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154506384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVERA MCKENNAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2008
-----------------------------------------------------
Last Update Date | 03/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 E COLLEGE DR STE. B
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258-4270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-337-2923
-----------------------------------------------------
Fax | 507-337-2926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 86370
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57118-6370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-322-7510
-----------------------------------------------------
Fax | 605-322-6475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VP OF FINANCE
-----------------------------------------------------
Name | JULIE N NORTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-322-6375
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------