Basic Information
| Provider Information | |||||||||
| NPI: | 1689638322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIDDENDORF | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8596554395 | ||||||||
| Practice Location | |||||||||
| Address1: | 5522 TAYLOR MILL RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR MILL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410152264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8574912855 | ||||||||
| FaxNumber: | 8596554395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20166 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0461441 | 05 | OH | MEDICAID | 64201668 | 05 | KY | MEDICAID |