Provider Demographics
NPI:1952324436
Name:SHERIDAN, ANTHONY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:THOMAS
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 1:12124 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9319
Mailing Address - Country:US
Mailing Address - Phone:906-248-5527
Mailing Address - Fax:906-248-5765
Practice Address - Street 1:12124 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-9319
Practice Address - Country:US
Practice Address - Phone:906-248-5527
Practice Address - Fax:906-248-5765
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0807334182OtherBSFEP
MI0807334182OtherBS
MI4514150OtherA43
MI0807334182OtherBSCOM
MI4514150OtherATENA
MI0807334182OtherBS3RD
MI3065475Medicaid
MI0807334182OtherBS2ND
MI0807334182OtherBS3RD
MI0807334182OtherBSCOM