Provider Demographics
NPI:1235341587
Name:SPANIER-STIASNY, JENNIFER A (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SPANIER-STIASNY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 TOWER CT STE C
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5711
Mailing Address - Country:US
Mailing Address - Phone:847-244-2960
Mailing Address - Fax:847-244-2986
Practice Address - Street 1:20 TOWER CT STE C
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5711
Practice Address - Country:US
Practice Address - Phone:847-244-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003998A207RG0100X
IL036.132905207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201068390Medicaid
IN146470004Medicare PIN