Basic Information
| Provider Information | |||||||||
| NPI: | 1235353616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDS | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | JUSTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 MCCLELLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176592279 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 MCCLELLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176592279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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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 | 207L00000X | 2007019256 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200264890A | 05 | OK | MEDICAID | 1235353616 | 05 | MO | MEDICAID | 200589100C | 05 | KS | MEDICAID |