Basic Information
| Provider Information | |||||||||
| NPI: | 1508178914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDEBOTTOM | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 LANSING ST | ||||||||
| Address2: | ATT: M.ROBERTS | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155670480 | ||||||||
| FaxNumber: | 3152557099 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 GENESEE ST STE 106 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130213390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155670555 | ||||||||
| FaxNumber: | 3155670308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 04/16/2018 | ||||||||
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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 | 208800000X | 280950 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 04198454 | 05 | NY | MEDICAID |