Basic Information
| Provider Information | |||||||||
| NPI: | 1487681599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMPSON | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 4703 | ND | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 4703 | ND | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 4703 | ND | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1600852 | 01 | ND | MEDICA FGO # | OTHER | 14146 | 05 | ND | MEDICAID | 9258 | 01 | ND | SIOUX VALLEY PROV # | OTHER | DA9011015581 | 01 | ND | PREF 1 # | OTHER | HP25764 | 01 | ND | HEALTHPARTNERS # | OTHER | 634208600 | 05 | ND | MEDICAID | 676650 | 01 | ND | ARAZ # | OTHER | 974 | 01 | ND | NDBS # | OTHER | 1600853 | 01 | ND | MEDICA INN # | OTHER | 91427SA | 01 | ND | MNBS # | OTHER |