Provider Demographics
NPI:1215952601
Name:SIDMAN, SALLY J (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:SIDMAN
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 1:1206 E. NATIONAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834
Mailing Address - Country:US
Mailing Address - Phone:812-442-2700
Mailing Address - Fax:812-442-2710
Practice Address - Street 1:1206 E. NATIONAL AVENUE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834
Practice Address - Country:US
Practice Address - Phone:812-442-2700
Practice Address - Fax:812-442-2710
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098644207P00000X
IN01042578A207P00000X
CAG74927207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098644OtherBLUE SHIELD
IN100381480Medicaid
IL036098644Medicaid
IN000000602172OtherBLUE SHIELD
IL206813003Medicare PIN
IN000000602172OtherBLUE SHIELD
F84399Medicare UPIN
IL036098644Medicaid