Provider Demographics
NPI:1174519466
Name:SHERIDAN, MICHAEL JAY SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY SCOTT
Last Name:SHERIDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1116 N 16TH ST STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8807
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA79395208G00000X
FLME 87486208G00000X
IN01069765A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78677OtherBCBS OF FL
FL841624482OtherTRICARE
IN000000851467OtherANTHEM PROVIDER NUMBER
FL266749500Medicaid
IN201023730Medicaid
FL78677SMedicare PIN
FL266749500Medicaid
IN201023730Medicaid
FL841624482OtherTRICARE
FLF79779Medicare UPIN
INP01559871Medicare PIN
FL78677WMedicare PIN