Provider Demographics
NPI:1669479432
Name:SPENCER, PETER BENJAMIN (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:BENJAMIN
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:230
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9159
Mailing Address - Country:US
Mailing Address - Phone:269-985-0000
Mailing Address - Fax:269-985-0360
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:230
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-985-0000
Practice Address - Fax:269-985-0360
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010106922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4170564Medicaid
MIF56617Medicare UPIN
MI4170564Medicaid