Provider Demographics
NPI:1508178914
Name:SIDEBOTTOM, RYAN C (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:C
Last Name:SIDEBOTTOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:17 LANSING ST
Mailing Address - Street 2:ATT: M.ROBERTS
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1983
Mailing Address - Country:US
Mailing Address - Phone:315-567-0480
Mailing Address - Fax:315-255-7099
Practice Address - Street 1:161 GENESEE ST STE 106
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3390
Practice Address - Country:US
Practice Address - Phone:315-567-0555
Practice Address - Fax:315-567-0308
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2018-04-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY280950208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04198454Medicaid