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	363LW0102X	Women's Health Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	370624200	OTHER	SD	DEPT OF LABOR
2	67B25MI	OTHER	MN	BLUE PLUS
3	67B25MI	OTHER	MN	BCBS
4	9177384	OTHER	SD	DAKOTACARE
5	0007280	OTHER	SD	BCBS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	74474	OTHER	SD	HEALTHPARTNERS
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255307450
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	:	911 E 20TH ST
Second Line	:	STE 200
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-1042
Country	:	US
Telephone Number	:	605-322-3455
Fax Number	:	605-322-3456

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	02/16/2021

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Directions to “AVERA MCKENNAN ” Practice Location

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