Provider Demographics
NPI:1720081243
Name:MELBY, SPENCER JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:JAMES
Last Name:MELBY
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:PO BOX 281490
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 W 800 N STE 444
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-6305
Practice Address - Country:US
Practice Address - Phone:801-743-4750
Practice Address - Fax:801-743-4765
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004010713208600000X, 208G00000X
UT13076265-1205208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208800003Medicaid
ILENROLLEDMedicaid
AL130970Medicaid
AL051120168OtherBCBS
ALI20806OtherVIVA
MOI20806Medicare UPIN
MS00420200Medicaid
MO208800003Medicaid
AL130974Medicaid
AL102I336894Medicare PIN
AL051120166OtherBCBS