Provider Demographics
NPI:1659683407
Name:ANNEBOINA, SIDHARTH (PT)
Entity Type:Individual
Prefix:MR
First Name:SIDHARTH
Middle Name:
Last Name:ANNEBOINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3678
Practice Address - Street 1:202 E VAN RIPER RD STE 200
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-7947
Practice Address - Country:US
Practice Address - Phone:517-223-2100
Practice Address - Fax:517-223-2101
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013970225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy