Provider Demographics
NPI:1255435814
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:400 PARK AVE.
Mailing Address - City:GREGORY
Mailing Address - State:SD
Mailing Address - Zip Code:57533-0408
Mailing Address - Country:US
Mailing Address - Phone:605-835-8394
Mailing Address - Fax:605-835-9422
Practice Address - Street 1:110 S LOGAN AVE
Practice Address - Street 2:
Practice Address - City:GREGORY
Practice Address - State:SD
Practice Address - Zip Code:57533-1614
Practice Address - Country:US
Practice Address - Phone:605-835-8394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD54875282NC0060X
261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5500350Medicaid
SD5500350Medicaid