Basic Information
| Provider Information | |||||||||
| NPI: | 1073580221 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SIDHU | ||||||||
| FirstName: | BALJIT | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045605595 | ||||||||
| FaxNumber: | 8045609029 | ||||||||
| Practice Location | |||||||||
| Address1: | 4710 PUDDLEDOCK RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PRINCE GEORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238751237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047320095 | ||||||||
| FaxNumber: | 8047320055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 12/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 0101031126 | VA | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207X00000X | 0101031126 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1073580221 | 01 | VA | MEDICARE RAILROAD | OTHER | 006408729 | 05 | VA | MEDICAID |