Provider Demographics
NPI:1841560992
Name:JEROME O SPRUILL MD PA
Entity Type:Organization
Organization Name:JEROME O SPRUILL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:O
Authorized Official - Last Name:SPRUILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-273-6911
Mailing Address - Street 1:1307 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6307
Mailing Address - Country:US
Mailing Address - Phone:336-273-6911
Mailing Address - Fax:336-273-9999
Practice Address - Street 1:1307 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6307
Practice Address - Country:US
Practice Address - Phone:336-273-6911
Practice Address - Fax:336-273-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28092207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8979040Medicaid
NCC81724Medicare UPIN