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	291U00000X	Clinical Medical Laboratory	43D0658878	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4995742	OTHER	SD	BLUE CROSS OF SD
2	604999	OTHER	SD	ARAZ
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1034593	OTHER	SD	PREFERRED ONE
5	165L6AV	OTHER	MN	BLUE CROSS OF MINNESOTA
6	F230764	OTHER	SD	MIDLANDS CHOICE
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891718136
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.
City	:	SIOUX FALLS
State	:	SD
Zip	:	57117-5045
Country	:	US
Telephone Number	:	605-322-7187
Fax Number	:	605-322-7183

Provider Business Practice Location Address
First Line	:	1301 S CLIFF AVE
Second Line	:	REGIONAL LAB
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-1005
Country	:	US
Telephone Number	:	605-322-7187
Fax Number	:	605-322-7183

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DAVID FLICEK
Credential	:
Telephone Number	:	605-322-7916

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	11/12/2020

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Directions to “AVERA MCKENNAN ” Practice Location

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