Basic Information
| Provider Information | |||||||||
| NPI: | 1033198981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADELL | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3262 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442575898 | ||||||||
| FaxNumber: | 3176636054 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315282541 | ||||||||
| FaxNumber: | 9315268814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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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 | 2085R0202X | 31227 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 38711931 | 05 | TN | MEDICAID | 4151229 | 01 | TN | BCBS PROVIDER NUMBER | OTHER | P00412122 | 01 | TN | RAILROAD MEDICARE | OTHER |