Healthcare Provider Details

I. General information

NPI: 1942301213
Provider Name (Legal Business Name): MICHAEL BRIAN SANDERS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17721 KY ROUTE 122
HI HAT KY
41636-6235
US

IV. Provider business mailing address

17721 KY ROUTE 122
HI HAT KY
41636-6235
US

V. Phone/Fax

Practice location:
  • Phone: 606-949-1006
  • Fax: 606-949-1026
Mailing address:
  • Phone: 606-949-1006
  • Fax: 606-949-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1053
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number03262
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number03262
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number03262
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: