1306808159 NPI number — DR. BOYD EDWIN SPRENKLE MD

Table of content: DR. BOYD EDWIN SPRENKLE MD (NPI 1306808159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306808159 NPI number — DR. BOYD EDWIN SPRENKLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPRENKLE
Provider First Name:
BOYD
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306808159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12502 WILLOWBROOK ROAD
Provider Second Line Business Mailing Address:
SUITE #280
Provider Business Mailing Address City Name:
CUMBERLAND
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21502-6494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-964-8750
Provider Business Mailing Address Fax Number:
240-964-8699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12502 WILLOWBROOK RD
Provider Second Line Business Practice Location Address:
SUITE #280
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502-6491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-964-8750
Provider Business Practice Location Address Fax Number:
240-964-8699
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  D0054946 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 774141301 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: K307-0014 . This is a "GHMSI" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 567B 768841-03 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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