1033149240 NPI number — GITA G SPRAGUE M.D.

Table of content: GITA G SPRAGUE M.D. (NPI 1033149240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033149240 NPI number — GITA G SPRAGUE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPRAGUE
Provider First Name:
GITA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1033149240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5514 CORPORATE DR STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64507-7754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-271-1350
Provider Business Mailing Address Fax Number:
816-271-1355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5514 CORPORATE DR STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64507-7754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-271-1350
Provider Business Practice Location Address Fax Number:
816-271-1355
Provider Enumeration Date:
07/04/2006

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: 207R00000X , with the licence number:  R1G86 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22979012 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 540156809 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10001331700 . This is a "COMMUNITY HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 100099580N , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1008065 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 603723 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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