=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972672194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVIN HENDERSON SIDES III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 PERIMETER PARK DR
-----------------------------------------------------
City | MORRISVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27560-9714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-481-5742
-----------------------------------------------------
Fax | 919-481-5707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1932 BRASSFIELD RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27614-9450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-847-9592
-----------------------------------------------------
Fax | 919-481-5707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 14767
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------