Provider Demographics
NPI:1487681599
Name:SAMPSON, JEROME M (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:M
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND47032085N0700X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1600852OtherMEDICA FGO #
ND14146Medicaid
ND9258OtherSIOUX VALLEY PROV #
NDDA9011015581OtherPREF 1 #
NDHP25764OtherHEALTHPARTNERS #
ND634208600Medicaid
ND676650OtherARAZ #
ND974OtherNDBS #
ND1600853OtherMEDICA INN #
ND91427SAOtherMNBS #
NDD26260Medicare UPIN
ND14146Medicaid
NDDA9011015581OtherPREF 1 #
ND713195Medicare PIN