Provider Demographics
NPI:1457342032
Name:ELDIDY, RENE JR (MD)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:ELDIDY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 9TH ST SE
Mailing Address - Street 2:CENTRACARE HEALTH SYSTEM - LONG PRAIRIE
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347-1404
Mailing Address - Country:US
Mailing Address - Phone:320-732-2131
Mailing Address - Fax:320-732-6913
Practice Address - Street 1:20 9TH ST SE
Practice Address - Street 2:CENTRACARE HEALTH SYSTEM - LONG PRAIRIE
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347-1404
Practice Address - Country:US
Practice Address - Phone:320-732-2131
Practice Address - Fax:320-732-6913
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN36275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1006863OtherPREFERRED ONE
54Q39ELOtherBLUE CROSS BLUE SHIELD
108065200OtherMEDICAL ASSISTANCE MA
C11369OtherRR MEDICARE
HP27075OtherHEALTH PARTNERS
080128013OtherRR MEDICARE
115064OtherUCARE
0128951OtherMEDICA HEALTH PLANS
638516OtherARAZ GROUP AMERICAS PPO
54Q39ELOtherBLUE CROSS BLUE SHIELD
F62775Medicare UPIN