MEDICARE: LISA SPACEK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	D57907	MD
2	207RI0200X	Infectious Disease Physician	MD433099	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124055058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SPACEK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 64264
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21264-4264
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 CHESTNUT ST STE 1020
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4310
Country	:	US
Telephone Number	:	215-955-7785
Fax Number	:	215-923-9362

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	10/25/2017

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