Basic Information
| Provider Information | |||||||||
| NPI: | 1376578088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANSARICQ | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7627 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330573 | ||||||||
| FaxNumber: | 2516337367 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 STANTON RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514790058 | ||||||||
| FaxNumber: | 2514791585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 17868 | AL | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207V00000X | 17868 | AL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 009982570 | 05 | AL | MEDICAID | 51506914 | 01 | AL | BCBS PROVIDER NUMBER | OTHER |