Provider Demographics
NPI:1366490062
Name:SIDNEY, SCOTT DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:DOUGLAS
Last Name:SIDNEY
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 1:7595 ANAGRAM DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7399
Mailing Address - Country:US
Mailing Address - Phone:612-573-2200
Mailing Address - Fax:612-573-2274
Practice Address - Street 1:7595 ANAGRAM DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7399
Practice Address - Country:US
Practice Address - Phone:612-573-2200
Practice Address - Fax:612-573-2274
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN501492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1366490062Medicaid
MN253802OtherMIDLANDS CHOICE, INC
MN954487900Medicaid
MN943381OtherPREFERRED ONE
ND1366490062OtherBLUE CROSS AND BLUE SHIELD OF NORTH DAKOTA
WI34872300Medicaid
MN134547OtherUCARE
MN6I349SIOtherBLUE CROSS AND BLUE SHIELD OF MINNESOTA
MN9250848OtherDAKOTA CARE
MN1366490062OtherMEDICA
MNP00406915OtherMEDICARE RAILROAD MN
WIP00737108OtherMEDICARE RAILROAD WI
MN1366490062OtherPREFERRED ONE
MNHP78846OtherHEALTHPARTNERS
WI006504070Medicare PIN
MN1366490062OtherPREFERRED ONE
MNH31596Medicare UPIN
WI34872300Medicaid
MN954487900Medicaid
MN300004213Medicare PIN