Basic Information
| Provider Information | |||||||||
| NPI: | 1366496705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPIRITOSO | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1742 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466341742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742333123 | ||||||||
| FaxNumber: | 5742333125 | ||||||||
| Practice Location | |||||||||
| Address1: | 5215 HOLY CROSS PARKWAY | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742333123 | ||||||||
| FaxNumber: | 5742333125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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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 | 01036184A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100091400 | 05 | IN | MEDICAID |