Basic Information
| Provider Information | |||||||||
| NPI: | 1780603530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDELL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 S PINE ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984097206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534766500 | ||||||||
| FaxNumber: | 2534766547 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 S PINE ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984097206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534766500 | ||||||||
| FaxNumber: | 2534766547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD61058340 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 01052695A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 200303280A | 05 | IN | MEDICAID |