MEDICARE: RICHARD S SPONG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	45487	MN
2	207RN0300X	Nephrology Physician	45487	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1936380	OTHER		ARAZ
3	31-00223	OTHER		MEDICA - CHOICE
4	1034834	OTHER		PREFERREDONE
5	131139	OTHER		UCARE
6	31-00223	OTHER		MEDICA - PRIMARY
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	435R4SP	OTHER	MN	BLUECROSS BLUESHIELD
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	HP39753	OTHER		HEALTHPARTNERS

General Provider Information

NPI Number	:	1689651093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD S SPONG M.D.

Provider Business Mailing Address
First Line	:	420 DELAWARE ST SE MMC 736
Second Line	:	UNIVERSITY OF MINNESOTA PHYSICIANS
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55455-0356
Country	:	US
Telephone Number	:	612-624-9444
Fax Number	:	612-626-3840

Provider Business Practice Location Address
First Line	:	516 DELWARE ST SE PWB CLINIC 2A
Second Line	:	UNIVERSITY OF MINNESOTA PHYSICIANS
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55455-0356
Country	:	US
Telephone Number	:	612-624-9444
Fax Number	:	612-626-3840

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	05/17/2012

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