Active NPI
Mark Edward Middendorf, MD
- Family Medicine Physician
- Taylor Mill, KY
National Provider Identifier
1689638322
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 20166
- Practice address
- 5522 Taylor Mill Rd
Taylor Mill, KY 41015-2264 - Phone
- (857) 491-2855
- Fax
- (859) 655-4395
- NPI assigned
- Apr 12, 2006
- Last updated
- Sep 28, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 20166 | KY | Primary |
Addresses
Primary practice location
5522 Taylor Mill Rd
Taylor Mill, KY 41015-2264
Mailing address
2300 Chamber Center Dr
Lakeside Park, KY 41017-1673
Phone (859) 344-5555
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 64201668 | Medicaid | KY | |
| 0461441 | Medicaid | OH |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 20166 | KY | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Summit Medical Group, Inc. | Past | Accepting new patients | |
| St Elizabeth Medical Center, Inc | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Community/Retail Pharmacy
- Florence, KY
- NPI 1104699453
-
dba St. Elizabeth Physicians
- Foot & Ankle Surgery Podiatrist
- Crestview Hills, KY
- NPI 1043188378
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1144800000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1443398400000",
"number": "1689638322",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2300 CHAMBER CENTER DR",
"city": "LAKESIDE PARK",
"state": "KY",
"postal_code": "410171673",
"telephone_number": "859-344-5555",
"fax_number": "859-655-4395"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5522 TAYLOR MILL RD",
"city": "TAYLOR MILL",
"state": "KY",
"postal_code": "410152264",
"telephone_number": "857-491-2855",
"fax_number": "859-655-4395"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MIDDENDORF",
"first_name": "MARK",
"middle_name": "EDWARD",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-04-12",
"last_updated": "2015-09-28",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "KY",
"license": "20166",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "64201668",
"state": "KY"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0461441",
"state": "OH"
}
],
"endpoints": [],
"other_names": []
}Other providers in Taylor Mill, KY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.