Provider Demographics
NPI:1073529475
Name:SIDWELL, STANLEY J IV (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:SIDWELL
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:618-463-7240
Mailing Address - Fax:618-463-7216
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7240
Practice Address - Fax:618-463-7216
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5A64207R00000X
IL036063407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360634071Medicaid
K06859Medicare ID - Type Unspecified
IL0360634071Medicaid