MEDICARE: MICHAEL J SAMMARCO MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	4301071412	MI
2	207V00000X	Obstetrics & Gynecology Physician	2012009159	MO
3	207V00000X	Obstetrics & Gynecology Physician	036069461	IL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	104773	OTHER	MI	GLHP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5885	OTHER	MI	HPM
4	03621	OTHER	MI	PHC
5	1604601321	OTHER	MI	BCBS MI
6	4057483	OTHER	MI	AETNA
7	000000356510	OTHER		ANTHEM
8	116023	OTHER	MI	CARE CHOICES
9	116023	OTHER	MI	PREFERRED CHOICES
10	160059932	OTHER	MI	RRMC

NPI Number	:	1609878420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J SAMMARCO MD

Provider Business Mailing Address
First Line	:	180 S MAIN ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-2608
Country	:	US
Telephone Number	:	309-647-0201
Fax Number	:	309-649-5101

Provider Business Practice Location Address
First Line	:	180 S MAIN ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-2608
Country	:	US
Telephone Number	:	309-647-0201
Fax Number	:	309-649-6880

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	04/15/2016

2050 CUMMING HWY , SUITE 100
CANTON, GA
30114-8614

Practice Phone: 770-345-9600
Practice Fax: