Provider Demographics
NPI:1003577081
Name:SPARTAN MEDICAL GROUP
Entity Type:Organization
Organization Name:SPARTAN MEDICAL GROUP
Other - Org Name:SPARTAN MEDICAL MEN'S HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KWABENA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMPONSAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-902-2068
Mailing Address - Street 1:10524 MOSS PARK RD STE 204-771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9145 NARCOOSSEE RD STE A102
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5768
Practice Address - Country:US
Practice Address - Phone:407-703-6020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-03
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty