Provider Demographics
NPI:1811189467
Name:MICHAEL M. SHERIDAN,D.O.
Entity Type:Organization
Organization Name:MICHAEL M. SHERIDAN,D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-843-5793
Mailing Address - Street 1:5010 STATE HIGHWAY 30
Mailing Address - Street 2:SUITE 101
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7532
Mailing Address - Country:US
Mailing Address - Phone:518-843-5793
Mailing Address - Fax:518-843-6513
Practice Address - Street 1:5010 STATE HIGHWAY 30
Practice Address - Street 2:SUITE 101
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7532
Practice Address - Country:US
Practice Address - Phone:518-843-5793
Practice Address - Fax:518-843-6513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL M. SHERIDAN, D.O.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01170667Medicaid
NY01170667Medicaid
NY53245AMedicare PIN