Provider Demographics
NPI:1689718702
Name:STEPHEN C SPAIN
Entity Type:Organization
Organization Name:STEPHEN C SPAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SPAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-534-0911
Mailing Address - Street 1:1702 HOLLY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0907
Mailing Address - Country:US
Mailing Address - Phone:903-543-0911
Mailing Address - Fax:
Practice Address - Street 1:455 RICE RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-534-0911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
89X859OtherBLUE CROSS
89X859OtherBLUE CROSS
C22090Medicare UPIN