Basic Information
| Provider Information | |||||||||
| NPI: | 1033195656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPANO | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559811042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515655600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 W GRANT ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550411143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513453321 | ||||||||
| FaxNumber: | 6513451151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36426 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 49A86SP | 01 | BCBS | OTHER | 118169 | 01 | UCARE | OTHER | MH9101008904 | 01 | PREFERRED ONE | OTHER | 080125255 | 01 | RAILROAD MEDICARE | OTHER | 925515000 | 05 | MN | MEDICAID | 0113159 | 01 | MEDICA | OTHER |