Provider Demographics
NPI:1801835913
Name:SANDFORD, JACK T (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:SANDFORD
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 1:1020A E BOAL AVE
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1509
Mailing Address - Country:US
Mailing Address - Phone:814-237-8627
Mailing Address - Fax:814-238-0083
Practice Address - Street 1:10286 FLEMING RD
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-3351
Practice Address - Country:US
Practice Address - Phone:618-985-4000
Practice Address - Fax:618-985-4155
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361044282085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104428Medicaid
IL10027422OtherIL BCBS
IL920006203Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IL036104428Medicaid
ILF80719Medicare UPIN