Healthcare Provider Details

I. General information

NPI: 1740449024
Provider Name (Legal Business Name): PHILIP MATTHEW SPENCE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax: 601-364-1394
Mailing address:
  • Phone: 601-362-4471
  • Fax: 601-364-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number28364
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: