Provider Demographics
NPI:1386906097
Name:SIDARI, KELLY M
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SIDARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-1762
Mailing Address - Country:US
Mailing Address - Phone:607-737-5565
Mailing Address - Fax:607-737-2980
Practice Address - Street 1:425 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-1762
Practice Address - Country:US
Practice Address - Phone:607-737-5565
Practice Address - Fax:607-737-2980
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-09
Last Update Date:2012-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY251BMedicaid