1588658744 NPI number — WAYNE T SPEARS MD

Table of content: WAYNE T SPEARS MD (NPI 1588658744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588658744 NPI number — WAYNE T SPEARS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPEARS
Provider First Name:
WAYNE
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1588658744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6950 FRANCE AVE S
Provider Second Line Business Mailing Address:
# 200
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-2008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-920-4915
Provider Business Mailing Address Fax Number:
952-915-6091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6500 EXCELSIOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55426-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-993-6032
Provider Business Practice Location Address Fax Number:
952-993-5512
Provider Enumeration Date:
09/02/2005

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: 2085R0001X , with the licence number:  33410 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2400004 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 25141 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 40635SP . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 104842 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2419297 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 889200800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP14447 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 110587 . This is a "PATIENT CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 963070250009 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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