Provider Demographics
NPI:1730173634
Name:SPROUSE, LARRY RICHARD II (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:RICHARD
Last Name:SPROUSE
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CITICO AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1127
Mailing Address - Country:US
Mailing Address - Phone:423-697-2000
Mailing Address - Fax:423-697-2320
Practice Address - Street 1:2501 CITICO AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1127
Practice Address - Country:US
Practice Address - Phone:423-697-2000
Practice Address - Fax:423-697-2320
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD35273208600000X, 2085R0204X, 208600000X
TN352732086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515824Medicaid
AL009933539Medicaid
GA611990120AMedicaid
AL009933539Medicaid
TN1515824Medicaid
3891426Medicare PIN
TN1515824Medicaid
P00159363OtherRR MEDICARE
4570789OtherCIGNA