Provider Demographics
NPI:1467559138
Name:SIDDALL MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:SIDDALL MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIDDALL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:907-585-6415
Mailing Address - Street 1:PO BOX 70851
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-0851
Mailing Address - Country:US
Mailing Address - Phone:907-585-6415
Mailing Address - Fax:907-585-6244
Practice Address - Street 1:200 A ST
Practice Address - Street 2:CLEAR AFS
Practice Address - City:CLEAR
Practice Address - State:AK
Practice Address - Zip Code:99704-5360
Practice Address - Country:US
Practice Address - Phone:907-585-6415
Practice Address - Fax:907-585-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X
AK036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty