Provider Demographics
NPI:1770545956
Name:SIDHU, KANWALDEEP S (MD)
Entity type:Individual
Prefix:DR
First Name:KANWALDEEP
Middle Name:S
Last Name:SIDHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23829 LITTLE MACK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1186
Mailing Address - Country:US
Mailing Address - Phone:586-773-1300
Mailing Address - Fax:586-773-1600
Practice Address - Street 1:23829 LITTLE MACK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1186
Practice Address - Country:US
Practice Address - Phone:586-773-1300
Practice Address - Fax:586-773-1600
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIKS054699207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3164740Medicaid
MIC4763OtherMCARE
MI0826968OtherBLUE CROSS BLUE SHIELD
MIC4763OtherMCARE
MI0826968OtherBLUE CROSS BLUE SHIELD