Provider Demographics
NPI:1780603530
Name:SIDELL, GREGORY SCOTT (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:SIDELL
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 1:4301 S PINE ST STE 301
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7206
Mailing Address - Country:US
Mailing Address - Phone:253-476-6500
Mailing Address - Fax:253-476-6547
Practice Address - Street 1:4301 S PINE ST STE 301
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7206
Practice Address - Country:US
Practice Address - Phone:253-476-6500
Practice Address - Fax:253-476-6547
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD610583402084P0800X
IN01052695A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200303280AMedicaid
IN200303280AMedicaid
INE80240Medicare UPIN
IN200303280AMedicaid
IN562950YMedicare ID - Type Unspecified