Healthcare Provider Details

I. General information

NPI: 1811950306
Provider Name (Legal Business Name): JAMES RANDALL SIDES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MARKET ST
DENTON MD
21629-2141
US

IV. Provider business mailing address

420 COLONIAL DR
DENTON MD
21629-3055
US

V. Phone/Fax

Practice location:
  • Phone: 410-479-1388
  • Fax: 410-479-3007
Mailing address:
  • Phone: 410-548-2343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberD0031376
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: