Provider Demographics
NPI:1891716833
Name:EIDAM, DIANE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:EIDAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3400 W 66TH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2109
Mailing Address - Country:US
Mailing Address - Phone:952-920-8088
Mailing Address - Fax:763-302-4219
Practice Address - Street 1:3400 W 66TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2109
Practice Address - Country:US
Practice Address - Phone:952-920-8088
Practice Address - Fax:763-302-4219
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10A51EIOtherBCBS OF MN
MN6429736OtherMEDICA
MN962871010735OtherPREFERRED ONE
MN793845OtherAMERICA'S PPO
MNHP44376OtherHEALTHPARTNERS