Healthcare Provider Details

I. General information

NPI: 1295796985
Provider Name (Legal Business Name): THOMAS S SPENCER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E CULVER RD SUITE 103
KNOX IN
46534-2216
US

IV. Provider business mailing address

2335 W BROOKS BLUFF
NORTH JUDSON IN
46366
US

V. Phone/Fax

Practice location:
  • Phone: 574-772-2114
  • Fax: 574-772-2802
Mailing address:
  • Phone: 574-933-1420
  • Fax: 574-772-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number22329
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01053871A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000518052
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM BLUE CROSS
# 2
Identifier200860120
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: