Healthcare Provider Details

I. General information

NPI: 1770545956
Provider Name (Legal Business Name): KANWALDEEP S SIDHU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23829 LITTLE MACK AVE SUITE 100
SAINT CLAIR SHORES MI
48080-1186
US

IV. Provider business mailing address

23829 LITTLE MACK AVE SUITE 100
SAINT CLAIR SHORES MI
48080-1186
US

V. Phone/Fax

Practice location:
  • Phone: 586-773-1300
  • Fax: 586-773-1600
Mailing address:
  • Phone: 586-773-1300
  • Fax: 586-773-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberKS054699
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: