Healthcare Provider Details

I. General information

NPI: 1700825452
Provider Name (Legal Business Name): JUDE FRANCIS SIDARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W CHESTNUT ST
HAZLETON PA
18201-6230
US

IV. Provider business mailing address

235 W CHESTNUT ST
HAZLETON PA
18201-6230
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-3339
  • Fax: 570-455-2939
Mailing address:
  • Phone: 570-455-3339
  • Fax: 570-455-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD040325L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0012196990002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier149219
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE ID
# 3
Identifier1022921120001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 4
Identifier147232
Identifier TypeOTHER
Identifier State
Identifier IssuerBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: