Provider Demographics
NPI:1659397511
Name:SIDAGAM, VASU (MD)
Entity Type:Individual
Prefix:
First Name:VASU
Middle Name:
Last Name:SIDAGAM
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 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084545207R00000X, 208M00000X
OH35.084545207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH364011OtherWELLCARE
OH000000221222OtherUNISON
OH000000503543OtherANTHEM
OHP00209940OtherRAILROAD MEDICARE
OH742838OtherBUCKEYE
OH7752646OtherAETNA
OHP00397868OtherRAILROAD MEDICARE
OH2496053Medicaid
OHP00397868OtherRAILROAD MEDICARE
OH742838OtherBUCKEYE
OHSI4142033Medicare PIN