Basic Information
| Provider Information | |||||||||
| NPI: | 1942861679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAUB | ||||||||
| FirstName: | SPENSER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 ASHLEY AVENUE | ||||||||
| Address2: | MUSC GME OFFICE, ROOM 202, MUH, MSC 333 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437927365 | ||||||||
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| Practice Location | |||||||||
| Address1: | 169 ASHLEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437924074 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2019 | ||||||||
| LastUpdateDate: | 06/24/2019 | ||||||||
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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 | LL82915 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | LL82915 | 05 | SC | MEDICAID |