Provider Demographics
NPI:1720261266
Name:JEAN A SANSARICQ MD PC
Entity Type:Organization
Organization Name:JEAN A SANSARICQ MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANSARICQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-479-0058
Mailing Address - Street 1:PO BOX 851255
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-1255
Mailing Address - Country:US
Mailing Address - Phone:251-479-0058
Mailing Address - Fax:251-479-1585
Practice Address - Street 1:524 STANTON RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2343
Practice Address - Country:US
Practice Address - Phone:251-479-0058
Practice Address - Fax:251-479-1585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17868207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529910760Medicaid
ALJ917Medicare PIN