Basic Information
| Provider Information | |||||||||
| NPI: | 1124228788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDAU | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566696061 | ||||||||
| FaxNumber: | 8566658053 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566652017 | ||||||||
| FaxNumber: | 8564886769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MB08471200 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0199125 | 05 | NJ | MEDICAID |