1033326947 NPI number — KANWALDEEP SIDHU MD

Table of content: KANWALDEEP SIDHU MD (NPI 1033326947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033326947 NPI number — KANWALDEEP SIDHU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIDHU
Provider First Name:
KANWALDEEP
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033326947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10765 LANTERN ROAD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FISHERS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46038-3597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-621-4181
Provider Business Mailing Address Fax Number:
317-621-4182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10765 LANTERN ROAD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FISHERS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46038-3597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-621-4181
Provider Business Practice Location Address Fax Number:
317-621-4182
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  01066327 A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000691248 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000721380 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200944150 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000637200 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 9676336 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000684780 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01191777 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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