MEDICARE: DR. SANDY POPHAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	35304	MN
2	207RN0300X	Nephrology Physician	35304	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3100318	OTHER	MN	MEDICA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	04N96P0	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1043269228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDY POPHAM MD

Provider Business Mailing Address
First Line	:	1001 E SUPERIOR ST STE L201
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-2207
Country	:	US
Telephone Number	:	218-249-7980
Fax Number	:	218-249-7911

Provider Business Practice Location Address
First Line	:	1001 E SUPERIOR ST STE L201
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-2207
Country	:	US
Telephone Number	:	218-249-7980
Fax Number	:	218-249-7911

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	01/20/2021

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