Provider Demographics
NPI:1689651093
Name:SPONG, RICHARD S (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:SPONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:420 DELAWARE ST SE MMC 736
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0356
Mailing Address - Country:US
Mailing Address - Phone:612-624-9444
Mailing Address - Fax:612-626-3840
Practice Address - Street 1:516 DELWARE ST SE PWB CLINIC 2A
Practice Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-624-9444
Practice Address - Fax:612-626-3840
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-05-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN45487207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0577080Medicaid
1936380OtherARAZ
31-00223OtherMEDICA - CHOICE
1034834OtherPREFERREDONE
131139OtherUCARE
31-00223OtherMEDICA - PRIMARY
WI34508900Medicaid
MT0072998Medicaid
MN435R4SPOtherBLUECROSS BLUESHIELD
MN488970300Medicaid
HP39753OtherHEALTHPARTNERS
MT0072998Medicaid
31-00223OtherMEDICA - CHOICE
MN488970300Medicaid