=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609867779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD W SPANN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2005
-----------------------------------------------------
Last Update Date | 12/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 E HARRY ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67218-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-268-5000
-----------------------------------------------------
Fax | 316-689-5873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 542N LONGFORD LN
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-634-2078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 04-13573
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 04-13573
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------