Provider Demographics
NPI:1841284262
Name:EIDSNESS, LUANN (MD)
Entity type:Individual
Prefix:
First Name:LUANN
Middle Name:
Last Name:EIDSNESS
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-312-7607
Mailing Address - Fax:605-312-7611
Practice Address - Street 1:1205 S GRANGE AVE
Practice Address - Street 2:STE 510
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0407
Practice Address - Country:US
Practice Address - Phone:605-328-0020
Practice Address - Fax:605-328-0021
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3342207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6002040Medicaid
MN563007000Medicaid
SDE25684Medicare UPIN
SDS845Medicare ID - Type Unspecified