Basic Information
| Provider Information | |||||||||
| NPI: | 1639325012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPANAKIS | ||||||||
| FirstName: | ILIAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64442 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103288040 | ||||||||
| FaxNumber: | 4434623514 | ||||||||
| Practice Location | |||||||||
| Address1: | 827 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212014606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436826800 | ||||||||
| FaxNumber: | 4435522991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2008 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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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 | 207R00000X | 237477 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | D74858 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 062287700 | 05 | MD | MEDICAID | S062-0544 | 01 | MD | CAREFIRST BC/BS | OTHER |