Basic Information
| Provider Information | |||||||||
| NPI: | 1083671929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPADY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5985 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376025985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239151126 | ||||||||
| FaxNumber: | 4239150635 | ||||||||
| Practice Location | |||||||||
| Address1: | 2511 WESLEY ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239523050 | ||||||||
| FaxNumber: | 4239523055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD0000019387 | TN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 3042014 | 05 | TN | MEDICAID |