Basic Information
| Provider Information | |||||||||
| NPI: | 1720261266 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEAN A SANSARICQ MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 851255 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366851255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514790058 | ||||||||
| FaxNumber: | 2514791585 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 STANTON RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514790058 | ||||||||
| FaxNumber: | 2514791585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | SANSARICQ | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2514790058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 17868 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 529910760 | 05 | AL | MEDICAID |