Healthcare Provider Details

I. General information

NPI: 1821776576
Provider Name (Legal Business Name): SPENCER GINES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 SUMMIT DR
WATERFORD MI
48328-3364
US

IV. Provider business mailing address

279 SUMMIT DR
WATERFORD MI
48328-3364
US

V. Phone/Fax

Practice location:
  • Phone: 248-745-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number343934
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704398546
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: