MEDICARE: DR. EVIN HENDERSON SIDES III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	14767	NC

General Provider Information

NPI Number	:	1972672194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVIN HENDERSON SIDES III MD

Provider Business Mailing Address
First Line	:	1932 BRASSFIELD RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-9450
Country	:	US
Telephone Number	:	919-847-9592
Fax Number	:	919-481-5707

Provider Business Practice Location Address
First Line	:	200 PERIMETER PARK DR
Second Line	:
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-9714
Country	:	US
Telephone Number	:	919-481-5742
Fax Number	:	919-481-5707

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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