Provider Demographics
NPI:1821020066
Name:SPELLMAN, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:SPELLMAN
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 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-2525
Mailing Address - Fax:701-234-2910
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2525
Practice Address - Fax:701-234-2910
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23785207RG0100X
ND4002207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND110145988Medicare PIN
D28694Medicare UPIN
NDN1624Medicare PIN