Healthcare Provider Details

I. General information

NPI: 1427025295
Provider Name (Legal Business Name): ALAN R. SANDIDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3619 RICHARDSON SQUARE DR SUITE 170
ARNOLD MO
63010
US

IV. Provider business mailing address

3619 RICHARDSON SQUARE DR SUITE 170
ARNOLD MO
63010
US

V. Phone/Fax

Practice location:
  • Phone: 636-717-6776
  • Fax: 314-525-4055
Mailing address:
  • Phone: 636-717-6776
  • Fax: 314-525-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2002003294
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: