Provider Demographics
NPI:1003814435
Name:SIDHOM, GEORGE S (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:S
Last Name:SIDHOM
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:PO BOX 10478
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34603-0478
Mailing Address - Country:US
Mailing Address - Phone:352-688-6393
Mailing Address - Fax:352-688-1113
Practice Address - Street 1:5193 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-1834
Practice Address - Country:US
Practice Address - Phone:352-688-6393
Practice Address - Fax:352-688-1113
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066412208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376854600Medicaid
FLE95833Medicare UPIN
FL376854600Medicaid
FL26415WMedicare PIN