Avera McKennan
Organization Active NPI Rural Health Clinic/Center · Rock Rapids, IA
NPI 1003389206 · NPPES record last updated Sep 14, 2023
Key facts
- NPI
- 1003389206
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- AVERA MCKENNAN
- Practice address
- 1100 S 10TH Ave
Ste 100
Rock Rapids, IA 51246-2020 - Phone
- (712) 472-5300
- NPI assigned
- Jan 10, 2019
- Organization subpart
- No
Authorized official
- Name
- Ronald J. Place, MD
- Title
- President/Ceo
- Phone
- (605) 322-7903
Owners & managing parties with NPI records 5
-
Jawad Nazir, MD
-
Alisa L Reindl, MD
Other NPIs on the same Medicare enrollment 25
Change of ownership 1
Facilities with the same owner 90
Practitioners 34
-
Sarah E. Cam, ARNP
-
Brett William Hutton, ARNP
-
Daulton Jay Keiser, FNP-C
-
Kimberly Sue Metzger, ARNP
-
Alexis Mae Semmler, NP-C
-
David James Springer, M.D.
-
Abby Van Zee, CN-P
-
Sadia Aslam, MBBS
-
Elie R. Balesh, MD
-
Kyle D Busack, PA
-
Michelle E Davis, NP
-
Germaine R Fritz, D.O.
-
Shandon Hatch, M.D.
-
Mark James Jameson, MD PHD
-
Shawn Lerew, D.O.
-
Lucas John Mikkelsen, PA-C
-
Crystal Minor, FNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 16D2161072 | Avera Medical Group, Rock Rapids | Certificate of waiver | Jan 24, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in SD, IA
Rural health clinic certification: CCN 168507
- Legal name
- AVERA MCKENNAN
- Doing business as
- AVERA MEDICAL GROUP ROCK RAPIDS
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- May 1, 2005
- Last certification
- Oct 6, 2022
- Ownership / control type
- 2B
- Most recent change of ownership
- May 1, 2019 (1 total)
- Organization structure
- Corporation · Non-profit
- Incorporated
- May 23, 1925 in SD
- Enrollment address
- 1100 S 10TH Ave
Rock Rapids, IA 51246-2020
All disclosed owners & managing parties 24
| Name | Role | Since | Share |
|---|---|---|---|
| Alisa L Reindl |
Corporate Director |
Jul 1, 2021 | |
| James Francis Dover |
Corporate Officer |
Oct 23, 2023 | |
| Van Fishback |
Corporate Director | May 1, 2019 | |
| Candyce C Chrystal |
Corporate Director |
Jul 1, 2023 | |
| Craig Hohn |
W-2 Managing Employee | May 1, 2019 | |
| Harriet Yocum |
Corporate Director |
Jul 1, 2021 | |
| Jennifer Bunkers |
Corporate Director |
Jul 1, 2021 | |
| Randy Knecht |
Corporate Director | May 1, 2019 | |
| Joseph Thomas Biegler |
Corporate Director | May 1, 2019 | |
| Jawad Nazir |
Corporate Director |
Jul 1, 2020 | |
| Lucille F Welbig |
Corporate Director | May 1, 2019 | |
| Joseph Patrick Costello |
Corporate Director | May 1, 2019 | |
| Laurie Knutson |
Corporate Director | May 1, 2019 | |
| Brenda K Kallemeyn |
Corporate Director |
Jul 1, 2023 | |
| Jennifer Kirby |
Corporate Director |
Jul 1, 2020 | |
| Alejandro Ramirez |
Corporate Director | May 1, 2019 | |
| Ronald J. Place |
Corporate Officer |
Jun 5, 2023 | |
| Operational/Managerial Control | Jun 5, 2023 | ||
| Julie Lautt |
Corporate Officer |
Mar 1, 2020 | |
| Mary C Curran |
Corporate Director | May 1, 2019 | |
| Avera Health |
5% Or Greater Direct Ownership Interest | May 1, 2019 | 100% |
| Roxanne P Seifert |
Corporate Director |
Jul 1, 2022 | |
| Jeffrey Gordon |
Corporate Director |
Jul 1, 2023 | |
| Cristina a Hill Jensen |
Corporate Director | May 1, 2019 | |
| Benjamin M Solomon |
Corporate Director |
Jul 1, 2022 |
All facility ownership & control disclosures 9
| Facility | Type | Role | Since |
|---|---|---|---|
| Lakes Regional Healthcare |
Hospital | Operational/Managerial Control | Oct 24, 2022 |
| Avera Heart Hospital of South Dakota |
Hospital | 5% Or Greater Direct Ownership Interest (33.33%) | Oct 1, 2010 |
| Avera Holy Family Hospital |
Hospital | Operational/Managerial Control | Oct 6, 1994 |
| Avera Holy Family Hospital |
Hospital | Operational/Managerial Control | Jan 1, 2007 |
| Lakes Regional Healthcare |
Hospital | Operational/Managerial Control | Oct 24, 2022 |
| United Living Community |
Skilled nursing facility | Operational/Managerial Control | Nov 15, 2005 |
| Freeman Regional Health Services |
Rural health clinic | 5% Or Greater Direct Ownership Interest (50%) | May 1, 2011 |
| Freeman Regional Health Services |
Rural health clinic | 5% Or Greater Direct Ownership Interest (50%) | May 1, 2011 |
| Freeman Regional Health Services |
Rural health clinic | 5% Or Greater Direct Ownership Interest (50%) | May 1, 2011 |
Change-of-ownership history
| Date | Event | Counterparty |
|---|---|---|
| May 1, 2019 | Change of Ownership |
Sanford Health Rock Rapids Clinic |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031110000117 | SD | Part B Supplier - Clinic/Group Practice | 0345157103 |
Receives reassigned benefits from 1,418 practitioners This NPI is an additional NPI on the enrollment |
| O20040206000384 | IA | Part B Supplier - Clinic/Group Practice | 0345157103 |
Receives reassigned benefits from 91 practitioners 25 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Rock Valley, IA; Spirit Lake, IA; Spencer, IA; Sioux Center, IA; Sibley, IA; Rock Rapids, IA; Milford, IA; Mason City, IA… |
| O20190530001006 | IA | Part a Provider - Rural Health Clinic | 0345157103 | Practice locations: Rock Rapids, IA |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
1100 S 10TH Ave
Ste 100
Rock Rapids, IA 51246-2020
Mailing address
PO Box 5045
Cbo PRV Enrlmt Palm Place
Sioux Falls, SD 57117-5045
Phone (605) 322-6428
Other names
- AVERA MEDICAL GROUP ROCK RAPIDS
Other providers in Rock Rapids, IA
- Ryan M. Ackerman
- Avera McKennan
- Avera McKennan
- Emma Baker
- Bamboo Acupuncture and Chinese Medicine LLC
- Matthew J Boer
All providers in Rock Rapids, IA · Rural Health Clinic/Center in Iowa
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 14, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.