Provider Demographics
NPI:1285955203
Name:LALICH, IAN J (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:J
Last Name:LALICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:612-672-7272
Mailing Address - Fax:
Practice Address - Street 1:6401 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4341
Practice Address - Country:US
Practice Address - Phone:612-626-5900
Practice Address - Fax:612-884-0659
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2025-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54175207YS0012X, 207Y00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN040001067Medicare PIN