Basic Information
| Provider Information | |||||||||
| NPI: | 1366490062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDNEY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Practice Location | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 50149 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1366490062 | 05 | IA | MEDICAID | 253802 | 01 | MN | MIDLANDS CHOICE, INC | OTHER | 954487900 | 05 | MN | MEDICAID | 943381 | 01 | MN | PREFERRED ONE | OTHER | 1366490062 | 01 | ND | BLUE CROSS AND BLUE SHIELD OF NORTH DAKOTA | OTHER | 34872300 | 05 | WI | MEDICAID | 134547 | 01 | MN | UCARE | OTHER | 6I349SI | 01 | MN | BLUE CROSS AND BLUE SHIELD OF MINNESOTA | OTHER | 9250848 | 01 | MN | DAKOTA CARE | OTHER | 1366490062 | 01 | MN | MEDICA | OTHER | P00406915 | 01 | MN | MEDICARE RAILROAD MN | OTHER | P00737108 | 01 | WI | MEDICARE RAILROAD WI | OTHER | 1366490062 | 01 | MN | PREFERRED ONE | OTHER | HP78846 | 01 | MN | HEALTHPARTNERS | OTHER |