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DSH430016A AVERA MCKENNAN (Active)
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Main Details
Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Internal Medicine
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH430016A
Medicare Provider Number
430016
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
12/15/2008
Participating Start Date
1/1/2009
Participating Approval Date
12/15/2008
Last Recertification Date
8/28/2024
Contacts
Authorizing Official
Avera
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Primary Contact
Avera
Brandy Friesen, Pharmacy Regulatory Analyst
(605) 322-8446
Addresses
Street Address
1301 S CLIFF AVE
STE 400
SIOUX FALLS, SD 57105
Billing Address
Avera McKennan Hospital
PO BOX 5045
Sioux Falls, SD 57117
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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3/27/12 UPDATED SUBDIV NAME (WAS AVERA GUTNIK AND ASSOCIATES); 9/17/08 DOC RECD TO CONFIRM ELIG DSH ADJ;05/05/11 UPDATED ADRR AND SUB-DIV NAME(WAS 1100 EAST 21ST STREET)
03/27/2012
9/17/08 DOC RECD TO CONFIRM ELIG DSH ADJ;05/05/11 UPDATED ADRR AND SUB-DIV NAME(WAS 1100 EAST 21ST STREET)
05/05/2011
April 2025
April 2025
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