Provider Demographics
NPI:1730524620
Name:LOVELACE, SPENCER CHARLES (MD)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:CHARLES
Last Name:LOVELACE
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 630
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127-0630
Mailing Address - Country:US
Mailing Address - Phone:803-364-4852
Mailing Address - Fax:
Practice Address - Street 1:600 N WHEELER AVE
Practice Address - Street 2:
Practice Address - City:PROSPERITY
Practice Address - State:SC
Practice Address - Zip Code:29127-9332
Practice Address - Country:US
Practice Address - Phone:803-364-4852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10047856390200000X
SCMMD39331207Q00000X
TXQ2583207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX575421OtherBASIC POSTGRADUATE PERMIT
SC393318Medicaid
SC393318Medicaid