Provider Demographics
NPI:1992814818
Name:KATY SHERIDAN MD PC
Entity type:Organization
Organization Name:KATY SHERIDAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-260-3121
Mailing Address - Street 1:154 W MARYDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7501
Mailing Address - Country:US
Mailing Address - Phone:907-260-3121
Mailing Address - Fax:907-260-4022
Practice Address - Street 1:154 W MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7501
Practice Address - Country:US
Practice Address - Phone:907-260-3121
Practice Address - Fax:907-260-4022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1581953Medicaid
AKK164926Medicare PIN
AKMD37231Medicaid