Basic Information
| Provider Information | |||||||||
| NPI: | 1326143439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPOO | ||||||||
| FirstName: | CHARISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4440 W 95TH ST | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086848000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4440 W 95TH | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086848000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036078515 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 036078515 | 05 | IL | MEDICAID | P00110671 | 01 | IL | RAILROAD | OTHER | 1618334 | 01 | IL | BCBS ID | OTHER |