Healthcare Provider Details

I. General information

NPI: 1285955203
Provider Name (Legal Business Name): IAN J LALICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 02/02/2025
Certification Date: 02/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 UNIVERSITY AVE NE
FRIDLEY MN
55432-4341
US

IV. Provider business mailing address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-5900
  • Fax: 612-884-0659
Mailing address:
  • Phone: 612-672-7272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number54175
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number54175
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: