Provider Demographics
NPI:1669779831
Name:SIDUN, CHARLES S (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:SIDUN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH VERSAILLES
Mailing Address - State:PA
Mailing Address - Zip Code:15137
Mailing Address - Country:US
Mailing Address - Phone:412-823-9300
Mailing Address - Fax:
Practice Address - Street 1:3019 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH VERSAILLES
Practice Address - State:PA
Practice Address - Zip Code:15137-1485
Practice Address - Country:US
Practice Address - Phone:412-823-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002544L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA198766Medicare PIN