Provider Demographics
NPI:1922020825
Name:SPANN, CARRELL RICE (MD)
Entity Type:Individual
Prefix:
First Name:CARRELL
Middle Name:RICE
Last Name:SPANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1301
Mailing Address - Country:US
Mailing Address - Phone:989-356-3485
Mailing Address - Fax:989-356-6396
Practice Address - Street 1:105 ARBOR LN
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1301
Practice Address - Country:US
Practice Address - Phone:989-356-3485
Practice Address - Fax:989-356-6396
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088986174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922020825Medicaid
C69013Medicare UPIN