Provider Demographics
NPI:1386173961
Name:SIDES, RANDALL WILLIAM (PT)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WILLIAM
Last Name:SIDES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MARTIN ARMY
Practice Address - Street 2:6600 VAN AALST BLVD, BLDG 9250
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:762-408-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist