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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	10563	SD

General Provider Information

NPI Number	:	1710316252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVERA MCKENNAN

Provider Business Mailing Address
First Line	:	PO BOX 5045
Second Line	:	ATTN: P.F.S. PROV ENROLLMENT
City	:	SIOUX FALLS
State	:	SD
Zip	:	57117-5045
Country	:	US
Telephone Number	:	605-322-6400
Fax Number	:	605-322-6499

Provider Business Practice Location Address
First Line	:	4210 W 53RD ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-4257
Country	:	US
Telephone Number	:	605-322-1490
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	RONALD JOSEPH PLACE
Credential	:	MD
Telephone Number	:	605-322-7903

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	08/07/2025

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Directions to “AVERA MCKENNAN ” Practice Location

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