Healthcare Provider Details

I. General information

NPI: 1417098658
Provider Name (Legal Business Name): KEVIN J LIUDAHL MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 PIERCE ST SUITE 101
SIOUX CITY IA
51104-3755
US

IV. Provider business mailing address

2800 PIERCE ST SUITE 101
SIOUX CITY IA
51104-3755
US

V. Phone/Fax

Practice location:
  • Phone: 712-224-8677
  • Fax: 712-277-1662
Mailing address:
  • Phone: 712-224-8677
  • Fax: 712-277-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25978
License Number StateIA

VIII. Authorized Official

Name: DR. KEVIN J LIUDAHL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 712-224-8677