Provider Demographics
NPI:1265541973
Name:SIDAWAY, BEN (PHD, PT)
Entity type:Individual
Prefix:PROF
First Name:BEN
Middle Name:
Last Name:SIDAWAY
Suffix:
Gender:M
Credentials:PHD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 GREEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04429-4523
Mailing Address - Country:US
Mailing Address - Phone:207-843-6137
Mailing Address - Fax:
Practice Address - Street 1:577 GREEN LAKE RD
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:ME
Practice Address - Zip Code:04429-4523
Practice Address - Country:US
Practice Address - Phone:207-843-6137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9679Medicare PIN