Provider Demographics
NPI:1821020009
Name:SHERIDAN, STEPHEN CLOVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CLOVIS
Last Name:SHERIDAN
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 1:105 ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1301
Mailing Address - Country:US
Mailing Address - Phone:989-356-3485
Mailing Address - Fax:989-356-6396
Practice Address - Street 1:105 ARBOR LN
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1301
Practice Address - Country:US
Practice Address - Phone:989-356-3485
Practice Address - Fax:989-356-6396
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISS070635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00281659OtherRR MEDICARE
MA382072742OtherTAX ID
MI4785908Medicaid
MISS070635OtherSTATE LICENSE
MI0Z47602010Medicare ID - Type Unspecified
MI4785908Medicaid