Provider Demographics
NPI:1316016520
Name:ANDERSON, SPENCER H (MD)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:H
Last Name:ANDERSON
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 1:4853 GALAXY PKWY
Mailing Address - Street 2:SUITE I
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5973
Mailing Address - Country:US
Mailing Address - Phone:216-831-9786
Mailing Address - Fax:216-831-2425
Practice Address - Street 1:4853 GALAXY PKWY
Practice Address - Street 2:SUITE I
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-5973
Practice Address - Country:US
Practice Address - Phone:216-831-9786
Practice Address - Fax:216-831-2425
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0519012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH816782Medicaid
OHE30133Medicare UPIN
OH816782Medicaid