Provider Demographics
NPI:1356379184
Name:SPANIOL, JACK P (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:SPANIOL
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 1:308 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3506
Mailing Address - Country:US
Mailing Address - Phone:309-663-5050
Mailing Address - Fax:309-662-3401
Practice Address - Street 1:308 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3506
Practice Address - Country:US
Practice Address - Phone:309-663-5050
Practice Address - Fax:309-662-3401
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-07300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073000Medicaid
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILK30464Medicare ID - Type UnspecifiedINDIVIDUAL #
ILB64919Medicare UPIN
IL833120Medicare ID - Type UnspecifiedGROUP #
IL036073000Medicaid