Healthcare Provider Details

I. General information

NPI: 1104036631
Provider Name (Legal Business Name): SID H SIAHPUSH MD, PHD. MPH, CGP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date: 10/22/2025
Reactivation Date: 11/19/2025

III. Provider practice location address

10500 BEARDSLEE BLVD UNIT 1665
BOTHELL WA
98041-0300
US

IV. Provider business mailing address

10500 BEARDSLEE BLVD UNIT 1665
BOTHELL WA
98041-0300
US

V. Phone/Fax

Practice location:
  • Phone: 425-209-0202
  • Fax: 425-818-4879
Mailing address:
  • Phone: 425-209-0202
  • Fax: 425-818-4879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number53335-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5465497134
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60240047
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier53335-20
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerWISCONSIN STATE LICENSE
# 2
IdentifierMD60240047
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerWA STATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: