Healthcare Provider Details

I. General information

NPI: 1417993353
Provider Name (Legal Business Name): MARTIN STEFAN SPAHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 FOUNDERS PARK DR SUITE 3
RAPID CITY SD
57701-8098
US

IV. Provider business mailing address

211 FOUNDERS PARK DR SUITE 3
RAPID CITY SD
57701-8098
US

V. Phone/Fax

Practice location:
  • Phone: 605-791-5959
  • Fax: 605-791-5960
Mailing address:
  • Phone: 605-791-5959
  • Fax: 605-791-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3471
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier6702250
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: