Basic Information
| Provider Information | |||||||||
| NPI: | 1063411999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPADARO | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733081301 | ||||||||
| FaxNumber: | 5732022480 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733081301 | ||||||||
| FaxNumber: | 5732022480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | R9324 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 10372 | 01 | BC/BS ID# | OTHER | 43-1571021 | 01 | TAX ID# | OTHER | 145792 | 01 | HEALTHLINK ID# | OTHER | 4040796 | 01 | AETNA ID# | OTHER | 202587614 | 05 | MO | MEDICAID | 8712 | 01 | GHP ID# | OTHER | 202587622 | 05 | MO | MEDICAID | 2500043 | 01 | UHC ID# | OTHER | 5512255 | 01 | CIGNA ID# | OTHER |