MEDICARE: DR. STEVEN J LIDVALL MD

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	207Q00000X	Family Medicine Physician	036059658	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013946649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEVEN J LIDVALL MD

Provider Business Mailing Address
First Line	:	PO BOX 1567
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61110-0067
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 N ALPINE RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-2201
Country	:	US
Telephone Number	:	815-391-7807
Fax Number	:

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	11/24/2009

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