Provider Demographics
NPI:1174683486
Name:SPENCER, RICHARD R (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:SPENCER
Suffix:
Gender:M
Credentials:CRNA
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 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E. THIRD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7608
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN35245163W00000X
GARN114857163W00000X
TNAPN8759367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAN366354OtherWELLCARE (GA MEDICAID)
AL009903630Medicaid
TN3067789OtherBLUE CROSS BLUE SHIELD TN
TN3604315Medicaid
NC8052086Medicaid
TN430060255OtherRAILROAD MEDICARE
GA00581721BMedicaid
TN3604317Medicare PIN