Healthcare Provider Details

I. General information

NPI: 1174519466
Provider Name (Legal Business Name): MICHAEL JAY SCOTT SHERIDAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 N 16TH ST STE A
LAFAYETTE IN
47904
US

IV. Provider business mailing address

PO BOX 5545
LAFAYETTE IN
47903-5545
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-448-8807
Mailing address:
  • Phone: 765-448-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number79395
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME 87486
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01069765A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: