Avera McKennan
Organization Active NPI Family Medicine Physician · Windom, MN
NPI 1851491690 · NPPES record last updated Jun 10, 2021
Key facts
- NPI
- 1851491690
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- AVERA MCKENNAN
- Practice address
- 2020 Hospital Dr., Ste. 2
Windom, MN 56101-1766 - Phone
- (507) 831-1703
- Fax
- (507) 831-5668
- NPI assigned
- Sep 22, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- AVERA MCKENNAN
Authorized official
- Name
- David William Flicek
- Title
- President/Ceo
- Phone
- (605) 322-7915
Other NPIs on the same Medicare enrollment 21
Member of 1
Practitioners 6
-
Stephanie C Buhler, M.D.
-
Bruce William Larkin, MD, MPH
-
Kylie J Cowdin, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D0680413 | Avera Medical Group - Windom | Accreditation | Dec 22, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040109001102 | MN | Part B Supplier - Clinic/Group Practice | 0345157103 |
Receives reassigned benefits from 81 practitioners 21 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Worthington, MN; Windom, MN; Tyler, MN; Slayton, MN; Pipestone, MN; Lakefield, MN; Ortonville, MN; Marshall, MN… |
National Provider Directory
- Part of
- Avera McKennan Hosp
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
2020 Hospital Dr., Ste. 2
Windom, MN 56101-1766
Mailing address
800 E 21St Street
PO Box5045
Sioux Falls, SD 57117-5045
Phone (605) 322-6375
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| C18643 | Other | RAILROAD MEDICARE | |
| 433903700 | Medicaid | MN |
Other names
- Avera Medical Group Windom
Other providers in Windom, MN
- Agape Counseling Center, LLC
- Joann Anderson
- Gloria Andreasen
- Avera Marshall
- Avera McKennan
- Barbara Jo Bennett
- Stanley Harold Bennett
- Tyler Bennett
- Mitchel Erickson Boeck
- Tabitha Nyaboke Bosire
All providers in Windom, MN · Family Medicine Physician in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 10, 2021. 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.
- 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.