=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740203272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES S SPANN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 W CHISHOLM ST
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-356-7390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5560 GRATIOT RD
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48638-6091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-791-9024
-----------------------------------------------------
Fax | 989-791-3702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 5666
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------