Provider Demographics
NPI:1942301213
Name:SANDERS, MICHAEL BRIAN (DO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17721 KY ROUTE 122
Mailing Address - Street 2:
Mailing Address - City:HI HAT
Mailing Address - State:KY
Mailing Address - Zip Code:41636-6235
Mailing Address - Country:US
Mailing Address - Phone:606-949-1006
Mailing Address - Fax:606-949-1026
Practice Address - Street 1:17721 KY ROUTE 122
Practice Address - Street 2:
Practice Address - City:HI HAT
Practice Address - State:KY
Practice Address - Zip Code:41636-6235
Practice Address - Country:US
Practice Address - Phone:606-949-1006
Practice Address - Fax:606-949-1026
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1053207R00000X
KY03262207RA0401X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100126820Medicaid
KYK070290Medicare PIN