=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801835913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK T SANDFORD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2006
-----------------------------------------------------
Last Update Date | 10/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10286 FLEMING RD
-----------------------------------------------------
City | CARTERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62918-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-985-4000
-----------------------------------------------------
Fax | 618-985-4155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020A E BOAL AVE
-----------------------------------------------------
City | BOALSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16827-1509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-237-8627
-----------------------------------------------------
Fax | 814-238-0083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 036104428
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------