Provider Demographics
NPI:1437158698
Name:SIDELL, CHARLES M (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:SIDELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03581-4900
Mailing Address - Country:US
Mailing Address - Phone:603-752-7727
Mailing Address - Fax:603-752-2820
Practice Address - Street 1:630 MAIN ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:NH
Practice Address - Zip Code:03581-4900
Practice Address - Country:US
Practice Address - Phone:603-752-7727
Practice Address - Fax:603-752-2820
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH531-0498111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0501745Y0NH01OtherANTHEM BLUE CROSS BLUE SH
NH30250401Medicaid
NH41581OtherCIGNA
NHRE7157Medicare ID - Type Unspecified
NH0501745Y0NH01OtherANTHEM BLUE CROSS BLUE SH