Provider Demographics
NPI:1053329490
Name:SPADY, ROBERT NEAL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NEAL
Last Name:SPADY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S WASHINGTON
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843
Mailing Address - Country:US
Mailing Address - Phone:208-892-1346
Mailing Address - Fax:208-892-8306
Practice Address - Street 1:619 S WASHINGTON
Practice Address - Street 2:SUITE 203
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-892-1346
Practice Address - Fax:208-892-8306
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032566207R00000X
IDM5447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001761700Medicaid
WA1061589Medicaid
ID001761700Medicaid
D00640Medicare UPIN
WAGAB16368Medicare PIN