Provider Demographics
NPI:1629360342
Name:SIDES, AVERY LYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:AVERY
Middle Name:LYNE
Last Name:SIDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:L
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 HIGHWAY 71 S
Mailing Address - Street 2:FALL RIVER HEALTH SERVICES
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-8800
Mailing Address - Country:US
Mailing Address - Phone:605-745-8910
Mailing Address - Fax:
Practice Address - Street 1:1201 HIGHWAY 71 S
Practice Address - Street 2:FALL RIVER HEALTH SERVICES
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-8800
Practice Address - Country:US
Practice Address - Phone:605-745-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6455207Q00000X
SD1481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine