Healthcare Provider Details

I. General information

NPI: 1881634368
Provider Name (Legal Business Name): KHURSHEED A SIDDIQUI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WEST BROADWAY
DANVILLE KY
40422-1408
US

IV. Provider business mailing address

300 WEST BROADWAY
DANVILLE KY
40422-1408
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-0606
  • Fax: 859-236-0066
Mailing address:
  • Phone: 859-236-0606
  • Fax: 859-236-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number28741
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number28741
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number28741
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number28741
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number28741
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: