Provider Demographics
NPI:1821235359
Name:SIDHU MEDICAL ASSOC PC
Entity Type:Organization
Organization Name:SIDHU MEDICAL ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SURINDERPAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIDHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-473-2176
Mailing Address - Street 1:211 WEST ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757
Mailing Address - Country:US
Mailing Address - Phone:508-473-2176
Mailing Address - Fax:508-473-7395
Practice Address - Street 1:211 WEST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-473-2176
Practice Address - Fax:508-473-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56299207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ08998OtherBLUE SHIELD
MA0116505Medicaid
MAJ08998OtherBLUE SHIELD