Provider Demographics
NPI:1275704132
Name:SIDDIQUI MD & ASSOCIATES PSC
Entity Type:Organization
Organization Name:SIDDIQUI MD & ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NASIRUDDIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-394-0402
Mailing Address - Street 1:8011 NEW LAGRANGE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4781
Mailing Address - Country:US
Mailing Address - Phone:502-394-0402
Mailing Address - Fax:502-394-0480
Practice Address - Street 1:8011 NEW LAGRANGE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4781
Practice Address - Country:US
Practice Address - Phone:502-394-0402
Practice Address - Fax:502-394-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64242217Medicaid
KYC35477Medicare UPIN
KY7460Medicare PIN