1992058192 NPI number — EDWARD C SPOON JR MD LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992058192 NPI number — EDWARD C SPOON JR MD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD C SPOON JR MD LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1992058192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 GOLDRING AVE
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89106-4002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-382-2900
Provider Business Mailing Address Fax Number:
702-382-1980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 GOLDRING AVE
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89106-4002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-382-2900
Provider Business Practice Location Address Fax Number:
702-382-1980
Provider Enumeration Date:
10/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SPOON
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
CAREY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-382-2900

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  6595 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: V30374 . This is a "PTAN TYPE 1" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002019518 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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