Provider Demographics
NPI:1831281674
Name:SIDORENKO, ELENA I (MD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:I
Last Name:SIDORENKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0002
Mailing Address - Country:US
Mailing Address - Phone:608-785-0940
Mailing Address - Fax:
Practice Address - Street 1:700 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4783
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20965207RG0100X
CO43384207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS04-29606OtherMEDICAL LICENSE
CO48105031Medicaid
CO48105031Medicaid
CO801709Medicare ID - Type Unspecified