Provider Demographics
NPI:1295796985
Name:SPENCER, THOMAS S (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:SPENCER
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 1:2335 W BROOKS BLUFF
Mailing Address - Street 2:
Mailing Address - City:NORTH JUDSON
Mailing Address - State:IN
Mailing Address - Zip Code:46366
Mailing Address - Country:US
Mailing Address - Phone:574-933-1420
Mailing Address - Fax:574-772-2802
Practice Address - Street 1:104 E CULVER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2216
Practice Address - Country:US
Practice Address - Phone:574-772-2114
Practice Address - Fax:574-772-2802
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22329207PE0004X
IN01053871A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000518052OtherANTHEM BLUE CROSS
IN200860120Medicaid
H81071Medicare UPIN
IN200860120Medicaid