Provider Demographics
NPI:1336353705
Name:ERDAHL, LILLIAN (MD)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:ERDAHL
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-1727
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-1727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188335208600000X
MN106875208600000X
MN56862208600000X
IAMD41945208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MN020003432Medicare PIN