Provider Demographics
NPI:1073001491
Name:MATTHEWS, SPENCER
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-9460
Mailing Address - Fax:
Practice Address - Street 1:611 2ND LOOP RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-2820
Practice Address - Country:US
Practice Address - Phone:864-512-1475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC52657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC527264Medicaid