Healthcare Provider Details

I. General information

NPI: 1629482633
Provider Name (Legal Business Name): JACOB BENJAMIN SANNING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTH CARE DR
GREENVILLE IL
62246-1154
US

IV. Provider business mailing address

3635 VISTA AVE PO BOX 15250
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 618-664-1230
  • Fax:
Mailing address:
  • Phone: 314-577-8780
  • Fax: 314-577-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2017010069
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01082264A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: