NPIMap

Organization Active NPI

Avera McKennan

Doing business as Avera Medical Group Rock Rapids

  • Rural Health Clinic/Center
  • Rock Rapids, IA
National Provider Identifier
1003389206
Registry record updated Sep 14, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
AVERA MCKENNAN
Doing business as
Avera Medical Group Rock Rapids
Practice address
1100 S 10TH Ave
Ste 100
Rock Rapids, IA 51246-2020
Phone
(712) 472-5300
NPI assigned
Jan 10, 2019
Last updated
Sep 14, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 14, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ronald J. Place, MD
Title
President/Ceo
Phone
(605) 322-7903

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

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 1

  • AVERA MEDICAL GROUP ROCK RAPIDS Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD, IA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003389206. Details of each certification follow.

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
CorporationNon-profit
Incorporated
May 23, 1925 in SD
Enrollment address
1100 S 10TH Ave
Rock Rapids, IA 51246-2020

Other NPIs on the same Medicare enrollment 25

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 25

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D2161072Avera Medical Group, Rock Rapids1100 S 10TH Ave Suite 100, Rock Rapids, IA 51246Certificate of waiverJan 24, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 24

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Alisa L Reindl Individual Corporate DirectorBoard Member Jul 1, 2021
James Francis Dover Individual Corporate OfficerFache, President/Ceo Avera Health Oct 23, 2023
Van Fishback Individual Corporate Director May 1, 2019
Candyce C Chrystal Individual Corporate DirectorBoard Member Jul 1, 2023
Craig Hohn Individual W-2 Managing Employee May 1, 2019
Harriet Yocum Individual Corporate DirectorBoard Member Jul 1, 2021
Jennifer Bunkers Individual Corporate DirectorBoard Member Jul 1, 2021
Randy Knecht Individual Corporate Director May 1, 2019
Joseph Thomas Biegler Individual Corporate Director May 1, 2019
Jawad Nazir Individual Corporate DirectorBoard Member Jul 1, 2020
Lucille F Welbig Individual Corporate Director May 1, 2019
Joseph Patrick Costello Individual Corporate Director May 1, 2019
Laurie Knutson Individual Corporate Director May 1, 2019
Brenda K Kallemeyn Individual Corporate DirectorBoard Member Jul 1, 2023
Jennifer Kirby Individual Corporate DirectorBoard Member Jul 1, 2020
Alejandro Ramirez Individual Corporate Director May 1, 2019
Ronald J. Place Individual Corporate OfficerPresident/Ceo Jun 5, 2023
Operational/Managerial Control Jun 5, 2023
Julie Lautt Individual Corporate OfficerCfo Mar 1, 2020
Mary C Curran Individual Corporate Director May 1, 2019
Avera Health Organization, Sioux Falls, SD Corporation, Non-profit 5% Or Greater Direct Ownership Interest May 1, 2019 100%
Roxanne P Seifert Individual Corporate DirectorBoard Member Jul 1, 2022
Jeffrey Gordon Individual Corporate DirectorBoard Member Jul 1, 2023
Cristina a Hill Jensen Individual Corporate Director May 1, 2019
Benjamin M Solomon Individual Corporate DirectorBoard Member Jul 1, 2022

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 9

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Lakes Regional HealthcareSpirit Lake, IA, CCN 160124 Hospital Operational/Managerial Control Oct 24, 2022
Avera Heart Hospital of South DakotaSioux Falls, SD, CCN 430095 Hospital 5% Or Greater Direct Ownership Interest (33.33%) Oct 1, 2010
Avera Holy Family HospitalEstherville, IA, CCN 161351 Hospital Operational/Managerial Control Oct 6, 1994
Avera Holy Family HospitalEstherville, IA, CCN 16Z351 Hospital Operational/Managerial Control Jan 1, 2007
Lakes Regional HealthcareSpirit Lake, IA, CCN 16U124 Hospital Operational/Managerial Control Oct 24, 2022
United Living CommunityBrookings, SD, CCN 435079 Skilled nursing facility Operational/Managerial Control Nov 15, 2005
Freeman Regional Health ServicesMenno, SD, CCN 433444 Rural health clinic 5% Or Greater Direct Ownership Interest (50%) May 1, 2011
Freeman Regional Health ServicesBridgewater, SD, CCN 433443 Rural health clinic 5% Or Greater Direct Ownership Interest (50%) May 1, 2011
Freeman Regional Health ServicesMarion, SD, CCN 433445 Rural health clinic 5% Or Greater Direct Ownership Interest (50%) May 1, 2011

Facilities with the same owner 90

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 90

Change-of-ownership history 1

DateEventCounterparty
May 1, 2019 Change of OwnershipThis provider was the buyer Sanford Health Rock Rapids ClinicCCN 168507, IA, NPI 1245300557

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Practitioners 34

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 34

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1547078400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694649600000",
    "number": "1003389206",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5045",
            "address_2": "CBO PRV ENRLMT PALM PLACE",
            "city": "SIOUX FALLS",
            "state": "SD",
            "postal_code": "571175045",
            "telephone_number": "605-322-6428"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 S 10TH AVE",
            "address_2": "STE 100",
            "city": "ROCK RAPIDS",
            "state": "IA",
            "postal_code": "512462020",
            "telephone_number": "712-472-5300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AVERA MCKENNAN",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-01-10",
        "last_updated": "2023-09-14",
        "certification_date": "2023-09-14",
        "status": "A",
        "authorized_official_last_name": "PLACE",
        "authorized_official_first_name": "RONALD",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "605-322-7903",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AVERA MEDICAL GROUP ROCK RAPIDS",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "AVERA MEDICAL GROUP ROCK RAPIDS",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rock Rapids, IA

Sources for this page

Verify at the official NPI Registry.