1720058712 NPI number — DR. KATHLEEN M SHERIDAN MD

Table of content: DR. KATHLEEN M SHERIDAN MD (NPI 1720058712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720058712 NPI number — DR. KATHLEEN M SHERIDAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERIDAN
Provider First Name:
KATHLEEN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BELLIS
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
SHERIDAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720058712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1575 HIGHLANDS DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITITZ
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17543-7507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-393-1338
Provider Business Mailing Address Fax Number:
717-627-1817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1575 HIGHLANDS DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITITZ
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17543-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-393-1338
Provider Business Practice Location Address Fax Number:
717-627-1817
Provider Enumeration Date:
01/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD19898 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 270045 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: MD428219 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)