Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | LP04405 | RI |
Y | 111NI0900X | Internist | LP04405 | RI |
NPI | 1003302456 |
---|---|
Provider Name | Dr. Peter Sidhom |
First Address | Providence, RI 02908-4728 |
Second Address | Providence, RI 02908-4728 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2018 |
Last Update Date | 09/07/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
FR4639829-418 | DEA (01) | RI |
LP04405 | LICENSE (01) | RI |