Basic Information
| Provider Information | |||||||||
| NPI: | 1063642643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDWELL | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MERCHANT ST | ||||||||
| Address2: | STE 220 - CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135331199 | ||||||||
| FaxNumber: | 5136459827 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ROCKRIDGE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453222794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378369921 | ||||||||
| FaxNumber: | 9378361298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35.120438 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0078127 | 05 | OH | MEDICAID |