Basic Information
| Provider Information | |||||||||
| NPI: | 1629047980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDBERG | ||||||||
| FirstName: | SAMUEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 W 53RD ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528062440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213800 | ||||||||
| FaxNumber: | 5634213810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 W 53RD ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528062440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213800 | ||||||||
| FaxNumber: | 5634213810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21581 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1184432 | 05 | IA | MEDICAID |