Basic Information
| Provider Information | |||||||||
| NPI: | 1174611727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDRIDGE | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154561825 | ||||||||
| FaxNumber: | 2154565926 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD YORK RD STE 331 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154568220 | ||||||||
| FaxNumber: | 2154565820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS012640 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7298896 | 01 | PA | AETNA | OTHER | 1378633 | 01 | PA | AETNA | OTHER |