Healthcare Provider Details

I. General information

NPI: 1255351532
Provider Name (Legal Business Name): GEORGE SIDHOM MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5193 MARINER BLVD
SPRING HILL FL
34609-1834
US

IV. Provider business mailing address

PO BOX 10478
BROOKSVILLE FL
34603-0478
US

V. Phone/Fax

Practice location:
  • Phone: 352-688-6393
  • Fax: 352-688-1113
Mailing address:
  • Phone: 352-688-6393
  • Fax: 352-688-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JEAN M SIDHOM
Title or Position: BILLING/OFFICE MANAGER
Credential:
Phone: 352-688-6393