Provider Demographics
NPI:1275578403
Name:LIU, EDITHA A (MD)
Entity Type:Individual
Prefix:
First Name:EDITHA
Middle Name:A
Last Name:LIU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0900
Mailing Address - Country:US
Mailing Address - Phone:605-336-2140
Mailing Address - Fax:605-336-1677
Practice Address - Street 1:1200 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0900
Practice Address - Country:US
Practice Address - Phone:605-336-2140
Practice Address - Fax:605-336-1677
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5677208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6005164Medicaid
SD6005162Medicaid
SD6005163Medicaid
SDP00287730Medicare PIN
SDS100788Medicare PIN
SD6005163Medicaid
SD6005162Medicaid