=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831583426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT SPENCER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2015
-----------------------------------------------------
Last Update Date | 07/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2460 HYLAN BLVD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10306-3117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-226-5619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 197 VAN VORST ST APT 305
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07302-4754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-334-8057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number | 286003
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------