Basic Information
| Provider Information | |||||||||
| NPI: | 1194998021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 219672 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641219672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167817730 | ||||||||
| FaxNumber: | 8167816973 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 GLENN HENDREN DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167817200 | ||||||||
| FaxNumber: | 8167816973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2008 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 2010021700 | MO | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200018049 | 05 | MO | MEDICAID |