Provider Demographics
NPI:1255481883
Name:SPRUILL, JIMMY W (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:W
Last Name:SPRUILL
Suffix:
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 1:3560 DELAWARE ST
Mailing Address - Street 2:SUITE 601-A
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3067
Mailing Address - Country:US
Mailing Address - Phone:800-258-2016
Mailing Address - Fax:409-924-9696
Practice Address - Street 1:1275 MARVIN HANCOCK DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4935
Practice Address - Country:US
Practice Address - Phone:409-384-1951
Practice Address - Fax:409-924-9696
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2033207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1399511-25Medicaid
TX8142853OtherCIGNA
TX8R0098OtherBLUE CROSS BLUE SHIELD
TX5645622OtherAETNA
TXP00264261OtherRAILROAD MEDICARE
TX610986Medicare ID - Type Unspecified
TX8142853OtherCIGNA