Provider Demographics
NPI:1699873935
Name:WHITE, SIDNEY J (PT)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:J
Last Name:WHITE
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:WI
Mailing Address - Zip Code:54155-0365
Mailing Address - Country:US
Mailing Address - Phone:920-869-2711
Mailing Address - Fax:
Practice Address - Street 1:525 AIRPORT DR
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:WI
Practice Address - Zip Code:54155-9035
Practice Address - Country:US
Practice Address - Phone:920-869-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9950-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI396081138007OtherTRICARE NORTH
WI40450200Medicaid
WI40450200Medicaid
WI007207270Medicare ID - Type Unspecified