Healthcare Provider Details

I. General information

NPI: 1285249086
Provider Name (Legal Business Name): SPENCER FREDERICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 BARTSON RD
FREMONT OH
43420-9672
US

IV. Provider business mailing address

1925 HAYES AVE
SANDUSKY OH
44870-4737
US

V. Phone/Fax

Practice location:
  • Phone: 419-332-5524
  • Fax:
Mailing address:
  • Phone: 419-557-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC.2002674-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: