Basic Information
| Provider Information | |||||||||
| NPI: | 1609867779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPANN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 542N LONGFORD LN | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672061816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166342078 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3600 E HARRY ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672183713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685000 | ||||||||
| FaxNumber: | 3166895873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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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 | 261QP2300X | 04-13573 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QH0100X | 04-13573 | KS | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 100080790C | 05 | KS | MEDICAID |