Provider Demographics
NPI:1306149554
Name:SPRAYBERRY, MATTHEW DARRELL (CRNA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DARRELL
Last Name:SPRAYBERRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N. LAKE SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2987
Mailing Address - Country:US
Mailing Address - Phone:312-695-6868
Mailing Address - Fax:
Practice Address - Street 1:259 E ERIE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-695-0665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.478201163W00000X
NC223941163W00000X, 367500000X
IL209.019297367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053981Medicaid
SCNAN998Medicaid
NC2618567Medicare PIN