Provider Demographics
NPI:1427025295
Name:SANDIDGE, ALAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:R
Last Name:SANDIDGE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3619 RICHARDSON SQUARE DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010
Mailing Address - Country:US
Mailing Address - Phone:636-717-6776
Mailing Address - Fax:314-525-4055
Practice Address - Street 1:3619 RICHARDSON SQUARE DR
Practice Address - Street 2:SUITE 170
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010
Practice Address - Country:US
Practice Address - Phone:636-717-6776
Practice Address - Fax:314-525-4055
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2010-06-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2002003294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205929805Medicaid
MO1427025295Medicare PIN
H62326Medicare UPIN
MO205929805Medicaid