1992058192 NPI number — EDWARD C SPOON JR MD LTD

Table of content: (NPI 1992058192)

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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