Provider Demographics
NPI:1578686762
Name:SIRAJ SIDDIQI M.D PLLC
Entity Type:Organization
Organization Name:SIRAJ SIDDIQI M.D PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SIRAJ
Authorized Official - Middle Name:U
Authorized Official - Last Name:SIDDIQI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-225-9098
Mailing Address - Street 1:1019 COMMERCE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8779
Mailing Address - Country:US
Mailing Address - Phone:502-225-9098
Mailing Address - Fax:502-225-9851
Practice Address - Street 1:1019 COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-8779
Practice Address - Country:US
Practice Address - Phone:502-225-9098
Practice Address - Fax:502-225-9851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28062207R00000X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64280621Medicaid
KYF23741Medicare UPIN
KY1747401Medicare ID - Type Unspecified