Provider Demographics
NPI:1114949575
Name:SIA, EDWIN MICHAEL C (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN MICHAEL
Middle Name:C
Last Name:SIA
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 1:103 PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-6858
Mailing Address - Country:US
Mailing Address - Phone:863-421-1855
Mailing Address - Fax:863-421-2624
Practice Address - Street 1:103 PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6858
Practice Address - Country:US
Practice Address - Phone:863-421-1855
Practice Address - Fax:863-421-2624
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92906208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37251OtherBCBS
FL273638100Medicaid