Provider Demographics
NPI:1942214077
Name:SPENCE, BERT ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:ROBERT
Last Name:SPENCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6363 FRANCE AVE S
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2129
Mailing Address - Country:US
Mailing Address - Phone:952-920-7660
Mailing Address - Fax:952-920-2049
Practice Address - Street 1:6363 FRANCE AVE S
Practice Address - Street 2:SUITE 500
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2129
Practice Address - Country:US
Practice Address - Phone:952-920-7660
Practice Address - Fax:952-920-2049
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN19236208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND69140Medicare UPIN
MN340000405Medicare ID - Type Unspecified