Healthcare Provider Details

I. General information

NPI: 1801835913
Provider Name (Legal Business Name): JACK T SANDFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10286 FLEMING RD
CARTERVILLE IL
62918-3351
US

IV. Provider business mailing address

1020A E BOAL AVE
BOALSBURG PA
16827-1509
US

V. Phone/Fax

Practice location:
  • Phone: 618-985-4000
  • Fax: 618-985-4155
Mailing address:
  • Phone: 814-237-8627
  • Fax: 814-238-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036104428
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: