Basic Information
| Provider Information | |||||||||
| NPI: | 1568409241 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDHWA | ||||||||
| FirstName: | SOHRAB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 SUMNER ST | ||||||||
| Address2: | M201 | ||||||||
| City: | STOUGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 907 SUMNER ST | ||||||||
| Address2: | M201 | ||||||||
| City: | STOUGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 10/05/2010 | ||||||||
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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 | 207L00000X | 80668 | MA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 110005438A | 05 | MA | MEDICAID |