Basic Information
| Provider Information | |||||||||
| NPI: | 1841244266 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEPHEN A SPENCER MD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COASTAL DERMATOLOGY AND SKIN CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 494710 | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339491040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416132400 | ||||||||
| FaxNumber: | 9416132401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1617 TAMIAMI TRL | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339481040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416132400 | ||||||||
| FaxNumber: | 9416132401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 07/06/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPENCER | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9416132400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD PA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0047672 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00824 | 01 | FL | BC/BS FLORIDA GROUP NUMBE | OTHER | CH1886 | 01 | FL | RAILROAD MEDICARE GROUP | OTHER |