MEDICARE: GERALD ANTHONY SPARKS JR. MD

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	207P00000X	Emergency Medicine Physician	21976	AL
2	207Q00000X	Family Medicine Physician	00021976	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	510-03800	OTHER		BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1770533507	OTHER	AL	TRICARE SOUTH
4	51510991	OTHER	AL	BCBS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770533507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD ANTHONY SPARKS JR. MD

Provider Business Mailing Address
First Line	:	1903 HAND AVE
Second Line	:
City	:	BAY MINETTE
State	:	AL
Zip	:	36507-4112
Country	:	US
Telephone Number	:	251-937-7970
Fax Number	:	251-937-9260

Provider Business Practice Location Address
First Line	:	1903 HAND AVE
Second Line	:
City	:	BAY MINETTE
State	:	AL
Zip	:	36507-4112
Country	:	US
Telephone Number	:	251-937-7970
Fax Number	:	251-937-9260

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	02/02/2011

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