1154399483 NPI number — DR. TIM A SIDOR MD

Table of content: DR. TIM A SIDOR MD (NPI 1154399483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154399483 NPI number — DR. TIM A SIDOR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIDOR
Provider First Name:
TIM
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
1154399483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6900 PEARL ROAD
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
MIDDLEBURG HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44130-3639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-845-0900
Provider Business Mailing Address Fax Number:
440-845-7355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6681 RIDGE RD STE 411
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44129-5705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-446-8637
Provider Business Practice Location Address Fax Number:
216-201-8597
Provider Enumeration Date:
03/11/2006

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: 208800000X , with the licence number:  35041262S , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0489467 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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