JACK WOODWORTH SAMPLE II MD
NPI 1093393944
Surgery in Rochester, MN
About Jack Woodworth Sample Ii Md NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
JACK WOODWORTH SAMPLE II MD (NPI 1093393944) is an individual surgery provider in Rochester, Minnesota, licensed in Minnesota (72034) and active in the NPI registry since March 2021. He is enrolled in Medicare PECOS and is a graduate of University Of Toledo College Of Medicine (2021).
NPPES Registry Identity
Specialties & Licenses
Medicare Participation & PECOS CMS
Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.
Medicare Enrollment Status
Enrolled in Medicare and accepts Medicare assignment
Jack Woodworth Sample Ii Md is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.
Medicare Billing Reassignment
Medicare enrollment records show Jack Sample reassigns Medicare billing to 1 organization. The organization bills Medicare for the services this provider delivers there.
Rochester, MN 55905
- Reassigned Medicare billing, Minnesota enrollment
- 6,534 clinicians in this Medicare group
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Physician Visit Costs CMS claims · ZIP area
Typical Medicare office-visit costs in the 55905 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.
Other Providers at the Same Location NPPES 20
Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.
ROCHESTER, MN 55905
ROCHESTER, MN 55905
Frequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Jack Sample's NPI number?
The NPI number for Jack Sample is 1093393944. It was assigned to this individual provider in the NPPES registry on March 31, 2021.
Where is Jack Sample located?
Jack Sample practices at 200 1st St SW, Rochester, MN 55905. The listed phone number is (507) 284-2511.
What is Jack Sample's specialty?
The primary specialty registered for this NPI is Surgery with taxonomy code 208600000X.
Is Jack Sample enrolled in Medicare?
Yes. Jack Sample is registered in the Medicare PECOS system and accepts Medicare assignment, which means accepting the Medicare-approved amount as payment in full for covered services.
Which organization bills Medicare for Jack Sample's services?
According to the CMS Revalidation Reassignment List (October 2026 release), Jack Sample reassigns Medicare benefits to Mayo Clinic (Rochester, MN). The reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for Jack Sample's services. Reassignment records can lag staffing changes; confirm current arrangements with the organization.
When was this NPI record last updated?
The NPPES record for Jack Sample was last updated on August 11, 2022. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 4 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Jack Woodworth Sample II, MD · NPI 1093393944
Surgery physician in Rochester, Minnesota. Individual provider, active in the CMS NPPES registry since March 31, 2021.
## Identity
- **NPI:** 1093393944 (Entity type: Individual)
- **Enumerated:** March 31, 2021
- **Primary specialty:** Surgery · taxonomy 208600000X
- **State license:** 72034 (Minnesota)
- **Sole proprietor:** No
## Practice location
- **Address:** 200 1ST ST SW, Rochester, MN 55905-0001
- **Phone:** (507) 284-2511
## Medicare
- **Medicare:** Enrolled (PECOS); accepts Medicare assignment
- **Ordering & referring:** eligible for Part B labs & imaging, durable medical equipment, home health, power mobility devices
- **Bills Medicare through:** Mayo Clinic (NPI 1114343860, Rochester, MN), under Medicare reassignment (form CMS-855R) · CMS Revalidation Reassignment List, October 2026 release
- **Medical school:** University Of Toledo College Of Medicine, class of 2021
## Record status
- **NPPES last updated:** August 11, 2022
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Source: [NPI Profile](https://npiprofile.com/npi/1093393944) · Data from the CMS NPPES public registry.