Provider Demographics
NPI:1962547257
Name:SIDWELL, RANDY C (PT, MS, ATC)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:C
Last Name:SIDWELL
Suffix:
Gender:M
Credentials:PT, MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 18TH AVE STE D2
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3358
Mailing Address - Country:US
Mailing Address - Phone:208-232-6490
Mailing Address - Fax:208-234-4805
Practice Address - Street 1:333 N 18TH AVE STE D2
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3358
Practice Address - Country:US
Practice Address - Phone:208-232-6490
Practice Address - Fax:208-234-4805
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1535225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805846600Medicaid
ID805846600Medicaid