Provider Demographics
NPI:1598184665
Name:SIDHU, GURKANWAL (MD)
Entity Type:Individual
Prefix:MR
First Name:GURKANWAL
Middle Name:
Last Name:SIDHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5407
Mailing Address - Country:US
Mailing Address - Phone:516-395-8867
Mailing Address - Fax:
Practice Address - Street 1:2006 HOGBACK RD STE 1
Practice Address - Street 2:(ST. MARY MERCY OUTPATIENT PSYCHIATRIC SERVICES)
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9750
Practice Address - Country:US
Practice Address - Phone:734-786-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011056292084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry