Basic Information
| Provider Information | |||||||||
| NPI: | 1033327846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDORCZUK | ||||||||
| FirstName: | SILWANA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 194 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT KENT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047431428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077287300 | ||||||||
| FaxNumber: | 2077287838 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 MAIN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MADAWASKA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047561014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077287300 | ||||||||
| FaxNumber: | 2077287838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 08/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT185132 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 432768599 | 05 | ME | MEDICAID | 200069 | 01 | ANTHEM | OTHER |