Healthcare Provider Details

I. General information

NPI: 1043590102
Provider Name (Legal Business Name): KENNARD B SPROUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST VA MEDICAL CENTER
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

7805 N CRESTWOOD LN
BRAZIL IN
47834-8279
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-0000
  • Fax:
Mailing address:
  • Phone: 812-841-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number01029027A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: