MEDICARE: JOHN R LIDDICOAT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	209670	MA

General Provider Information

NPI Number	:	1750579694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN R LIDDICOAT M.D.

Provider Business Mailing Address
First Line	:	2208 OLIVER AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2441
Country	:	US
Telephone Number	:	763-360-7961
Fax Number	:

Provider Business Practice Location Address
First Line	:	7601 NORTHLAND DR N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55428-4500
Country	:	US
Telephone Number	:	763-360-7961
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2007
Last Update Date	:	10/04/2007

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