Provider Demographics
NPI:1184007122
Name:CHESTNUT CREEK ORTHOPEDICS AND SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:CHESTNUT CREEK ORTHOPEDICS AND SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SPROUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-238-0990
Mailing Address - Street 1:101 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2277
Mailing Address - Country:US
Mailing Address - Phone:276-238-0990
Mailing Address - Fax:276-238-1081
Practice Address - Street 1:101 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2277
Practice Address - Country:US
Practice Address - Phone:276-238-0990
Practice Address - Fax:276-238-1081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101254866207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty