Healthcare Provider Details

I. General information

NPI: 1215054994
Provider Name (Legal Business Name): SEAN SIDER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7602 BELAIR RD
BALTIMORE MD
21236-4088
US

IV. Provider business mailing address

6030 MARSHALEE DR STE 212
ELKRIDGE MD
21075-5987
US

V. Phone/Fax

Practice location:
  • Phone: 410-661-3338
  • Fax: 410-663-6984
Mailing address:
  • Phone: 410-661-3338
  • Fax: 410-844-4777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number01274
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: