Basic Information
| Provider Information | |||||||||
| NPI: | 1639147408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDBERG | ||||||||
| FirstName: | CHRIS | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645052631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162333338 | ||||||||
| FaxNumber: | 8162334777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 ST JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | ST JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645052631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162333338 | ||||||||
| FaxNumber: | 8162334777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35550 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | AS7555103 | 01 | DEA | OTHER | 202117610 | 05 | MO | MEDICAID |