Healthcare Provider Details

I. General information

NPI: 1104875632
Provider Name (Legal Business Name): ELIZABETH A LILJEBLAD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 LOBERG AVE
HERMANTOWN MN
55811-2652
US

IV. Provider business mailing address

4190 LOBERG AVE
HERMANTOWN MN
55811-2652
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-4600
  • Fax: 218-249-4666
Mailing address:
  • Phone: 218-249-4600
  • Fax: 218-249-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32718
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: