Healthcare Provider Details

I. General information

NPI: 1255788022
Provider Name (Legal Business Name): ROBERT MICHAEL SPRAGUE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROB MICHAEL SPRAGUE DO

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0721
  • Fax: 618-457-0469
Mailing address:
  • Phone: 186-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number008178
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036156247
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: