Provider Demographics
NPI:1851513436
Name:LIDLE, CALLEY A (MD)
Entity Type:Individual
Prefix:
First Name:CALLEY
Middle Name:A
Last Name:LIDLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CALLEY
Other - Middle Name:A
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:233 GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-9658
Mailing Address - Country:US
Mailing Address - Phone:651-227-7806
Mailing Address - Fax:651-256-6707
Practice Address - Street 1:233 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-9658
Practice Address - Country:US
Practice Address - Phone:651-227-7806
Practice Address - Fax:651-256-6707
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050402208000000X
MN51175208000000X
WI52074-020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN185153436Medicaid