Basic Information
| Provider Information | |||||||||
| NPI: | 1457514341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIDEN | ||||||||
| FirstName: | MATS | ||||||||
| MiddleName: | LARS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1450 NW 6035 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554856035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525428553 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 166 19TH STREET SOUTH | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SARTELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563772154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202510609 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5748 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 55109 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.