Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | IL |
NPI | 1730179482 |
---|---|
Provider Name | Douglas Sidle |
First Address | Chicago, IL 60611-4546 |
Second Address | Chicago, IL 60611-4546 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I13174 | (02) |