Provider Demographics
NPI:1962447169
Name:JORGENSON, SAMUEL STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:STEVEN
Last Name:JORGENSON
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 1:360 E MONTVUE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6318
Mailing Address - Country:US
Mailing Address - Phone:208-855-2900
Mailing Address - Fax:208-898-9788
Practice Address - Street 1:360 E MONTVUE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6318
Practice Address - Country:US
Practice Address - Phone:208-855-2900
Practice Address - Fax:208-898-9788
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8450207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF39420Medicare UPIN
ID1104125Medicare PIN