Basic Information
Provider Information | |||||||||
NPI: | 1720076680 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPENCER | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20 CATAMORE BLVD | ||||||||
Address2: |   | ||||||||
City: | EAST PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029141204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014322520 | ||||||||
FaxNumber: | 4014322457 | ||||||||
Practice Location | |||||||||
Address1: | 20 CATAMORE BLVD | ||||||||
Address2: |   | ||||||||
City: | EAST PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029141204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014322520 | ||||||||
FaxNumber: | 4014322457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5831 | RI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 000000001988 | 01 |   | NHPRI | OTHER | 005831 | 01 |   | BLUESHIELD | OTHER | 7000445 | 01 |   | RIMEDICALASSISTANCE | OTHER | 005831 | 01 |   | TUFTS | OTHER | 1600203 | 01 |   | UNITEDHEALTHPLANS | OTHER | 240159 | 01 |   | RIHPILGRIM | OTHER | 5831 | 01 |   | FEPBLUECROSS | OTHER | 004370 | 01 |   | BLUECHIPSENIORS | OTHER | 6192238 | 01 |   | HEALTHYSTART | OTHER | 6192238 | 01 |   | MASSMEDICAID | OTHER | 004370 | 01 |   | BLUECHIP | OTHER |