=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730340498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB DAVID SAMS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2008
-----------------------------------------------------
Last Update Date | 02/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 ASHLAND AVE.
-----------------------------------------------------
City | MT. ZION
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-864-2665
-----------------------------------------------------
Fax | 217-864-8042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9632
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62791-9632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-864-2665
-----------------------------------------------------
Fax | 217-864-8042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 036132006
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------