Healthcare Provider Details

I. General information

NPI: 1386887032
Provider Name (Legal Business Name): MICHAEL BRYON SPACKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E MONTVUE DR SUITE 100
MERIDIAN ID
83642
US

IV. Provider business mailing address

2835 N TANGLEROSE PL
EAGLE ID
83616-5796
US

V. Phone/Fax

Practice location:
  • Phone: 208-855-2900
  • Fax:
Mailing address:
  • Phone: 952-239-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberM11335
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: