Healthcare Provider Details

I. General information

NPI: 1184072084
Provider Name (Legal Business Name): STEPHEN SPANO BA, MBA, JD, CELA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 BROADWAY STE 201
SAUGUS MA
01906-3200
US

IV. Provider business mailing address

PO BOX 1345
SAUGUS MA
01906-0645
US

V. Phone/Fax

Practice location:
  • Phone: 781-231-7800
  • Fax: 781-231-7900
Mailing address:
  • Phone: 781-231-7800
  • Fax: 781-231-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number563975
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: