Basic Information
| Provider Information | |||||||||
| NPI: | 1609024926 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMY M SPRAGUE MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 211550 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309171550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068559860 | ||||||||
| FaxNumber: | 8887430249 | ||||||||
| Practice Location | |||||||||
| Address1: | 3651 WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309096521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068559860 | ||||||||
| FaxNumber: | 8887430249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2008 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | SPRAGUE | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7068559860 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 035145 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | G35145 | 05 | SC | MEDICAID |