Provider Demographics
NPI:1720117724
Name:SIDES, ANDREW W (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:W
Last Name:SIDES
Suffix:
Gender:M
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-293-7320
Mailing Address - Fax:803-293-7330
Practice Address - Street 1:1801 SUNSET DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6803
Practice Address - Country:US
Practice Address - Phone:803-545-1000
Practice Address - Fax:803-540-1050
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32135207R00000X
SC32135TL32135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC321351Medicaid
SC321351Medicaid