Provider Demographics
NPI:1841245743
Name:SIDAWAY, LARRY STEVEN (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:STEVEN
Last Name:SIDAWAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EAST THIRD STREET
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC MCL2CRED
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-1183
Mailing Address - Fax:
Practice Address - Street 1:3000 32ND AVENUE SOUTH
Practice Address - Street 2:ESSENTIA HEALTH 32ND AVENUE CLINIC
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6614207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
36623OtherHEALTH PARTNERS
MN41986380Medicaid
IA0501643Medicaid
SD6003420Medicaid
SD0005335OtherSD BCBS
MN36047SIOtherMN BCBS - PLAN 91057NO
SD4303OtherDAKOTACARE
931451029047OtherPREFERRED ONE
36623OtherHEALTH PARTNERS
IA0501643Medicaid
GA060046299Medicare PIN