Provider Demographics
NPI:1326531534
Name:SIDAROUS, LLC
Entity Type:Organization
Organization Name:SIDAROUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDAROUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-319-9672
Mailing Address - Street 1:11521 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2701
Mailing Address - Country:US
Mailing Address - Phone:501-502-2765
Mailing Address - Fax:501-302-1991
Practice Address - Street 1:11521 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2701
Practice Address - Country:US
Practice Address - Phone:501-502-2765
Practice Address - Fax:501-302-1991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE100-91207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR219215001Medicaid