Healthcare Provider Details

I. General information

NPI: 1770553851
Provider Name (Legal Business Name): JESUS C SIADY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 CREEKPORT DR
COLUMBIA KY
42728-2120
US

IV. Provider business mailing address

901 WESTLAKE DR
COLUMBIA KY
42728-1123
US

V. Phone/Fax

Practice location:
  • Phone: 270-250-9428
  • Fax:
Mailing address:
  • Phone: 270-384-4753
  • Fax: 270-385-9123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26032
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: