Healthcare Provider Details

I. General information

NPI: 1972618924
Provider Name (Legal Business Name): JEFFREY J LIUDAHL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRE SD
57501
US

IV. Provider business mailing address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRES SD
57501
US

V. Phone/Fax

Practice location:
  • Phone: 605-945-5202
  • Fax: 605-945-5294
Mailing address:
  • Phone: 605-945-5202
  • Fax: 605-945-5294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number1242
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: