Basic Information
| Provider Information | |||||||||
| NPI: | 1003279662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDES | ||||||||
| FirstName: | JAKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | 250 WEST | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376202200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238446620 | ||||||||
| FaxNumber: | 4238446626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | 250 WEST | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376203762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238446620 | ||||||||
| FaxNumber: | 4238446626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 63286 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.