Provider Demographics
NPI:1386684652
Name:SIDERS, BRUCE R (DO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:R
Last Name:SIDERS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3455 MILL RUN DRIVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-9083
Mailing Address - Country:US
Mailing Address - Phone:614-771-2222
Mailing Address - Fax:614-771-2221
Practice Address - Street 1:2658 W. LASKEY ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-3288
Practice Address - Country:US
Practice Address - Phone:419-473-8105
Practice Address - Fax:419-254-2121
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-03-25
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Provider Licenses
StateLicense IDTaxonomies
MI51010167002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2781520Medicaid
OH2781520Medicaid
4214271Medicare PIN