Provider Demographics
NPI:1467622753
Name:SELMA J. SHERIDAN MD
Entity Type:Organization
Organization Name:SELMA J. SHERIDAN MD
Other - Org Name:EYEWEAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SELMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-343-9022
Mailing Address - Street 1:209 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3676
Mailing Address - Country:US
Mailing Address - Phone:315-343-9022
Mailing Address - Fax:
Practice Address - Street 1:209 W 7TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3676
Practice Address - Country:US
Practice Address - Phone:315-343-9022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELMA J. SHERIDAN MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-03
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132758156FX1800X
NY1121450001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00554476Medicaid
NY35415BMedicare PIN
NY00554476Medicaid
NYB81513Medicare UPIN