Provider Demographics
NPI:1407850134
Name:SARIDAKIS, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:SARIDAKIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1300
Mailing Address - Country:US
Mailing Address - Phone:270-659-5945
Mailing Address - Fax:270-659-5855
Practice Address - Street 1:310 N L ROGERS WELLS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1300
Practice Address - Country:US
Practice Address - Phone:270-659-5945
Practice Address - Fax:270-659-5855
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29430208600000X
KY48331208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK130430OtherMEDICARE
KY7100356140Medicaid
TN3814598Medicaid
TN4276208OtherCIGNA
TN29166OtherTLC
TN3814598Medicaid
TN4076350OtherBCBS
TN5174505OtherAETNA
TN4076350OtherBCBS
TN148196OtherBETTER HEALTH PLANS