Provider Demographics
NPI: | 1821019845 |
---|---|
Name: | SIDANI, MOHAMAD ANIS (MD, MS) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MOHAMAD |
Middle Name: | ANIS |
Last Name: | SIDANI |
Suffix: | |
Gender: | M |
Credentials: | MD, MS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1005 DR DB TODD JR BLVD |
Mailing Address - Street 2: | FAMILY AND COMMUNITY MEDICINE DEPARTMENT |
Mailing Address - City: | NASHVILLE |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37208-3599 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 615-327-5817 |
Mailing Address - Fax: | 615-327-5634 |
Practice Address - Street 1: | MMC MEDICAL SHOOL FAMILY & COMMUNITY MEDICINE DEPARTME |
Practice Address - Street 2: | 1005 DR. D. B. TODD JR. BLVD. |
Practice Address - City: | NASHVILLE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37208-3599 |
Practice Address - Country: | US |
Practice Address - Phone: | 615-327-5817 |
Practice Address - Fax: | 615-327-5634 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-23 |
Last Update Date: | 2020-12-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | 41790 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 3335750 | Medicaid | |
TN | 3335750 | Medicare PIN | |
TN | 3335750 | Medicaid |