Provider Demographics
NPI:1972521847
Name:SIDITSKY, MARC L (RPA-C)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:L
Last Name:SIDITSKY
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 PORTLAND AVENUE
Mailing Address - Street 2:STE 309
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3008
Mailing Address - Country:US
Mailing Address - Phone:585-342-2638
Mailing Address - Fax:585-730-7500
Practice Address - Street 1:1445 PORTLAND AVENUE
Practice Address - Street 2:STE 309
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3008
Practice Address - Country:US
Practice Address - Phone:585-342-2638
Practice Address - Fax:585-730-7500
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000373363A00000X
NY000373-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01272146Medicaid
NY32989DMedicare PIN
NY01272146Medicaid