NPIMap

Organization Active NPI

Avera McKennan

Doing business as Avera Medical Group Wilmot

  • Rural Health Clinic/Center
  • Wilmot, SD
National Provider Identifier
1770680787
Registry record updated Sep 10, 2020
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 Wilmot
Practice address
409 4TH St
Wilmot, SD 57279-2214
Phone
(605) 938-4351
Fax
(605) 938-4351
NPI assigned
Sep 20, 2006
Last updated
Sep 10, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 10, 2020

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

Authorized official

Name
David Flicek
Title
President/Ceo
Phone
(605) 322-7916

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Nurse Practitioner 363L00000X

Addresses

Primary practice location

409 4TH St
Wilmot, SD 57279-2214

Mailing address

409 4TH St
Wilmot, SD 57279-2214
Phone (605) 938-4351

Other identifiers 2

IdentifierTypeStateIssuer
5300010MedicaidSD
43D0901649OtherSDCLIA #

Other names 1

  • AVERA MEDICAL GROUP WILMOT Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100423000334 SD Part A Provider - Rural Health Clinic 0345157103 Practice locations: Wilmot, SD

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1770680787. Details of each certification follow.

Rural health clinic certification: CCN 433876

Legal name
AVERA MCKENNAN
Doing business as
AVERA MEDICAL GROUP WILMOT
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 11, 1996
Last certification
Jan 21, 2026
Ownership / control type
2B
Most recent change of ownership
Feb 1, 1999 (1 total)
Organization structure
OtherNon-profit
Incorporated
May 23, 1925 in SD
Enrollment address
409 4TH St
Wilmot, SD 57279-2214

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
43D0901649Avera Medical Group Wilmot409 4TH Street, Wilmot, SD 57279Certificate of waiverJun 2, 2027

National Provider Directory

National Provider Directory
Tax ID family
Presentation Health Sys105 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Locations

409 4th St
Wilmot, SD 57279
Phone (605) 938-4351

Ownership & related parties

All disclosed owners & managing parties 21

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
Tamera L Sturm Individual Corporate DirectorBoard Member Jul 1, 2025
Patti Swenson Individual W-2 Managing EmployeeClinic Manager Jan 1, 1997
Van Fishback Individual Corporate DirectorBoard Member Jul 1, 2018
Candyce C Chrystal Individual Corporate DirectorBoard Member Jul 1, 2023
Harriet Yocum Individual Corporate DirectorBoard Member Jul 1, 2021
Jennifer Bunkers Individual Corporate DirectorBoard Member Jul 1, 2021
Randy Knecht Individual Corporate DirectorBoard Member Jul 1, 2018
Jawad Nazir Individual Corporate DirectorBoard Member Jul 1, 2020
Lucille F Welbig Individual Corporate DirectorBoard Member Jul 1, 2014
Joseph Patrick Costello Individual Corporate DirectorBoard Member Jul 1, 2017
Sanaa Abourezk Individual Corporate DirectorBoard Member Jul 1, 2024
Ryan Boschee Individual Corporate DirectorBoard Member Jul 1, 2024
Jennifer Kirby Individual Corporate DirectorBoard Member Jul 1, 2020
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 DirectorBoard Member Jul 1, 2018
Avera Health Organization, Sioux Falls, SD Corporation, Non-profit, Chain home office 5% Or Greater Direct Ownership Interest Jun 15, 1992 100%
Operational/Managerial Control Jun 15, 1992
Roxanne P Seifert Individual Corporate DirectorBoard Member Jul 1, 2022
Cristina a Hill Jensen Individual Corporate DirectorBoard Member Jul 1, 2018
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

NPI Registry JSON

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

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599696000000",
    "number": "1770680787",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "409 4TH ST",
            "city": "WILMOT",
            "state": "SD",
            "postal_code": "572792214",
            "telephone_number": "605-938-4351",
            "fax_number": "605-938-4351"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "409 4TH ST",
            "city": "WILMOT",
            "state": "SD",
            "postal_code": "572792214",
            "telephone_number": "605-938-4351",
            "fax_number": "605-938-4351"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AVERA MCKENNAN",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-20",
        "last_updated": "2020-09-10",
        "certification_date": "2020-09-10",
        "status": "A",
        "authorized_official_last_name": "FLICEK",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "605-322-7916"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5300010",
            "state": "SD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA #",
            "identifier": "43D0901649",
            "state": "SD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AVERA MEDICAL GROUP WILMOT",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "AVERA MEDICAL GROUP WILMOT",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wilmot, SD

Sources for this page

Verify at the official NPI Registry.