Provider Demographics
NPI:1851483515
Name:SAMPSON, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:513 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-3017
Mailing Address - Country:US
Mailing Address - Phone:218-387-2330
Mailing Address - Fax:218-387-1278
Practice Address - Street 1:513 5TH AVE W
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-3017
Practice Address - Country:US
Practice Address - Phone:218-387-2330
Practice Address - Fax:218-387-1278
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69144COOtherBCBS
MN536253900Medicaid
MN536253900Medicaid