Provider Demographics
NPI:1104872837
Name:SIDDEN, CHRISTOPHER R (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:SIDDEN
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 1:3620 PELHAM RD # 149
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 POLLY DRUMMOND HILL RD BLDG 4
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-5703
Practice Address - Country:US
Practice Address - Phone:585-218-8012
Practice Address - Fax:585-218-8099
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012447412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC329326Medicaid
SCGP5074Medicaid
SCGP1821Medicaid
SCGP5275Medicaid
SCGP5278Medicaid
SCGP5074Medicaid
SC329326Medicaid
MO103030001Medicare PIN