Provider Demographics
NPI:1659047298
Name:GREG SIDELL MD PLLC
Entity Type:Organization
Organization Name:GREG SIDELL MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT/EXECUTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SIDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-693-0022
Mailing Address - Street 1:4041 RUSTON WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5300
Mailing Address - Country:US
Mailing Address - Phone:253-693-0022
Mailing Address - Fax:
Practice Address - Street 1:4041 RUSTON WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5300
Practice Address - Country:US
Practice Address - Phone:253-693-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty