Healthcare Provider Details

I. General information

NPI: 1730340498
Provider Name (Legal Business Name): JACOB DAVID SAMS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 ASHLAND AVE.
MT. ZION IL
62549
US

IV. Provider business mailing address

PO BOX 9632
SPRINGFIELD IL
62791-9632
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-2665
  • Fax: 217-864-8042
Mailing address:
  • Phone: 217-864-2665
  • Fax: 217-864-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036132006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: