Basic Information
Provider Information | |||||||||
NPI: | 1841245743 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIDAWAY | ||||||||
FirstName: | LARRY | ||||||||
MiddleName: | STEVEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 EAST THIRD STREET | ||||||||
Address2: | ESSENTIA HEALTH DULUTH CLINIC MCL2CRED | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558051951 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187861183 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3000 32ND AVENUE SOUTH | ||||||||
Address2: | ESSENTIA HEALTH 32ND AVENUE CLINIC | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581036132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013648000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 6614 | ND | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 36623 | 01 |   | HEALTH PARTNERS | OTHER | 41986380 | 05 | MN |   | MEDICAID | 0501643 | 05 | IA |   | MEDICAID | 6003420 | 05 | SD |   | MEDICAID | 0005335 | 01 | SD | SD BCBS | OTHER | 36047SI | 01 | MN | MN BCBS - PLAN 91057NO | OTHER | 4303 | 01 | SD | DAKOTACARE | OTHER | 931451029047 | 01 |   | PREFERRED ONE | OTHER |