Healthcare Provider Details

I. General information

NPI: 1730173634
Provider Name (Legal Business Name): LARRY RICHARD SPROUSE II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CITICO AVE
CHATTANOOGA TN
37404-1127
US

IV. Provider business mailing address

2501 CITICO AVE
CHATTANOOGA TN
37404-1127
US

V. Phone/Fax

Practice location:
  • Phone: 423-697-2000
  • Fax: 423-697-2320
Mailing address:
  • Phone: 423-697-2000
  • Fax: 423-697-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD35273
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35273
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: