Basic Information
Provider Information | |||||||||
NPI: | 1265671408 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHARP | ||||||||
FirstName: | HEIDI | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SORRELL | ||||||||
OtherFirstName: | HEIDI | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635283 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452635283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8597814111 | ||||||||
FaxNumber: | 8594415214 | ||||||||
Practice Location | |||||||||
Address1: | 2626 ALEXANDRIA PIKE | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND HEIGHTS | ||||||||
State: | KY | ||||||||
PostalCode: | 410761530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8597814111 | ||||||||
FaxNumber: | 8594415214 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2009 | ||||||||
LastUpdateDate: | 04/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R1593 | KY | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 43344 | KY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7100134220 | 05 | KY |   | MEDICAID | P00856626 | 01 | KY | RAILROAD MEDICARE | OTHER | 3112090 | 05 | OH |   | MEDICAID |