MEDICARE: MRS. RACHEL SIDLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224P00000X	Prosthetist	195	TN
2	222Z00000X	Orthotist	215	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CPO 03218	OTHER		ABC

General Provider Information

NPI Number	:	1316470883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RACHEL SIDLE

Provider Business Mailing Address
First Line	:	6515 POPLAR AVE STE 112
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-4878
Country	:	US
Telephone Number	:	901-795-1776
Fax Number	:	901-795-1738

Provider Business Practice Location Address
First Line	:	6515 POPLAR AVE STE 112
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-4878
Country	:	US
Telephone Number	:	901-795-1776
Fax Number	:	901-795-1738

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	01/16/2019

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Directions to “ MRS. RACHEL SIDLE ” Practice Location

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