Provider Demographics
NPI:1336336130
Name:GEORGE SIDHOM MD PA
Entity type:Organization
Organization Name:GEORGE SIDHOM MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDHOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-688-6393
Mailing Address - Street 1:PO BOX 10478
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34603-0478
Mailing Address - Country:US
Mailing Address - Phone:813-684-7246
Mailing Address - Fax:813-684-0453
Practice Address - Street 1:722 BOWING OAK DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5974
Practice Address - Country:US
Practice Address - Phone:813-684-7246
Practice Address - Fax:813-684-0453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
97788OtherBLUE CROSS
97788OtherBLUE CROSS