1053375758 NPI number — DR. TIMOTHY EUGENE SPENCER JR. DO

Table of content: DR. TIMOTHY EUGENE SPENCER JR. DO (NPI 1053375758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053375758 NPI number — DR. TIMOTHY EUGENE SPENCER JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
TIMOTHY
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053375758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 153
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CERESCO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49033-0153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-841-4350
Provider Business Mailing Address Fax Number:
269-704-6125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14250 BEADLE LAKE RD
Provider Second Line Business Practice Location Address:
STE 160
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49014-7200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-841-4350
Provider Business Practice Location Address Fax Number:
269-704-6125
Provider Enumeration Date:
04/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  34.006663 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 5101017055 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1454111555 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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