Basic Information
| Provider Information | |||||||||
| NPI: | 1891717765 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TODD SPENCER MD MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SIERRA KINGS RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 E ALMOND AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936375692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596759281 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 372 W CYPRESS AVE | ||||||||
| Address2: | |||||||||
| City: | REEDLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936542113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596388155 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SPENCER | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5596759281 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0076592 | 05 | CA | MEDICAID |