Basic Information
| Provider Information | |||||||||
| NPI: | 1417098658 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEVIN J LIUDAHL MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 PIERCE ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511043755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122248677 | ||||||||
| FaxNumber: | 7122771662 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 PIERCE ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511043755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122248677 | ||||||||
| FaxNumber: | 7122771662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 11/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | LIUDAHL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7122248677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25978 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0464826 | 05 | IA | MEDICAID |