Provider Demographics
NPI:1417098658
Name:KEVIN J LIUDAHL MD, PC
Entity Type:Organization
Organization Name:KEVIN J LIUDAHL MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIUDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-224-8677
Mailing Address - Street 1:2800 PIERCE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3755
Mailing Address - Country:US
Mailing Address - Phone:712-224-8677
Mailing Address - Fax:712-277-1662
Practice Address - Street 1:2800 PIERCE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3755
Practice Address - Country:US
Practice Address - Phone:712-224-8677
Practice Address - Fax:712-277-1662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25978174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0464826Medicaid
IA5796280001Medicare NSC
IAA03402Medicare UPIN
IAI15532Medicare ID - Type Unspecified