Provider Demographics
NPI:1174611727
Name:SANDRIDGE, CARMEN (DO)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:
Last Name:SANDRIDGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-1825
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:5401 OLD YORK RD STE 331
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3045
Practice Address - Country:US
Practice Address - Phone:215-456-8220
Practice Address - Fax:215-456-5820
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012640207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7298896OtherAETNA
PA1378633OtherAETNA
PA7298896OtherAETNA