Provider Demographics
NPI:1477630432
Name:SIDERS, RICHARD WAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WAYNE
Last Name:SIDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:ATTN BARB SIMMONS
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-1603
Practice Address - Street 1:500 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT STE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783
Practice Address - Country:US
Practice Address - Phone:906-635-4438
Practice Address - Fax:906-635-4467
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010295312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4920637Medicaid
MIP41100006Medicare PIN
MIA76002075Medicare PIN