Provider Demographics
NPI:1629030598
Name:SPRAGUE, AMY M (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:M
Last Name:SPRAGUE
Suffix:
Gender:F
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:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-527-7000
Mailing Address - Fax:
Practice Address - Street 1:606 BLACK RIVER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3368
Practice Address - Country:US
Practice Address - Phone:843-527-7000
Practice Address - Fax:843-520-8403
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD195005207R00000X, 207RN0300X, 208M00000X
IDM15250207R00000X
GA035145207RN0300X
SC15949207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG35145Medicaid
GA035145OtherGA LICENSE #
GA000506701IMedicaid
SC15949OtherSC LICENSE #
GA035145OtherGA LICENSE #
GA39BDBRWMedicare ID - Type UnspecifiedGA MEDICARE
GA035145OtherGA LICENSE #
GA000506701IMedicaid