Provider Demographics
NPI:1760412654
Name:SPANOS, GEORGE (DO)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:SPANOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP
Mailing Address - Street 2:STE 604
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4436
Mailing Address - Country:US
Mailing Address - Phone:731-660-8759
Mailing Address - Fax:
Practice Address - Street 1:650 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-660-8759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN810207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3307622Medicaid
4106215OtherBCBS
P00276317OtherRR MEDICARE
TNE70310Medicare UPIN
TN3307622Medicaid