Provider Demographics
NPI:1194212605
Name:EIDE, EVAN R (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:EIDE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:2601 CENTENNIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3087
Practice Address - Country:US
Practice Address - Phone:651-777-7414
Practice Address - Fax:651-748-5839
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2021-10-21
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Provider Licenses
StateLicense IDTaxonomies
MN66030207Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine