MEDICARE: YANKTON EAR NOSE AND THROAT PC

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	207Y00000X	Otolaryngology Physician	0389	SD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CK4038	OTHER	SD	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0008554	OTHER	SD	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1801901863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YANKTON EAR NOSE AND THROAT PC

Provider Business Mailing Address
First Line	:	409 SUMMIT ST STE 2800
Second Line	:
City	:	YANKTON
State	:	SD
Zip	:	57078-3735
Country	:	US
Telephone Number	:	605-665-6820
Fax Number	:	605-665-6821

Provider Business Practice Location Address
First Line	:	409 SUMMIT ST STE 2800
Second Line	:
City	:	YANKTON
State	:	SD
Zip	:	57078-3735
Country	:	US
Telephone Number	:	605-665-6820
Fax Number	:	605-665-6821

Authorized Official
Title or Position	:	PROVIDER AND OWNER
Name	:	JEFFREY J LIUDAHL
Credential	:	MD
Telephone Number	:	605-665-6820

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	02/22/2013

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