Basic Information
| Provider Information | |||||||||
| NPI: | 1528390804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDHU | ||||||||
| FirstName: | AMANJOT | ||||||||
| MiddleName: | KAUR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAUR | ||||||||
| OtherFirstName: | AMANJOT | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5 NEPONSET ST FL STREET12 | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952300 | ||||||||
| FaxNumber: | 5088535226 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 NEPONSET ST FL STREET12 | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952300 | ||||||||
| FaxNumber: | 5088535226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2010 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 246536 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110089518/A | 05 | MA | MEDICAID |