Provider Demographics
NPI:1306930250
Name:H. SPRAGUE TAVEAU IV DO PA
Entity type:Organization
Organization Name:H. SPRAGUE TAVEAU IV DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HORATIO
Authorized Official - Middle Name:SPRAGUE
Authorized Official - Last Name:TAVEAU
Authorized Official - Suffix:IV
Authorized Official - Credentials:DO
Authorized Official - Phone:855-963-4325
Mailing Address - Street 1:2300 S CLEAR CREEK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4984
Mailing Address - Country:US
Mailing Address - Phone:855-963-4325
Mailing Address - Fax:855-963-4325
Practice Address - Street 1:2300 S CLEAR CREEK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4984
Practice Address - Country:US
Practice Address - Phone:855-963-4325
Practice Address - Fax:855-963-4325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0696208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140005324Medicaid
TXE03551Medicare UPIN