MEDICARE: DOUGLAS M SPENCE JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301074856	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790875649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS M SPENCE JR. MD

Provider Business Mailing Address
First Line	:	1225 W FRONT ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2317
Country	:	US
Telephone Number	:	231-935-0788
Fax Number	:	231-935-0787

Provider Business Practice Location Address
First Line	:	1225 W FRONT ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2317
Country	:	US
Telephone Number	:	231-935-0788
Fax Number	:	231-935-0787

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	12/30/2011

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