MEDICARE: DR. ROMAN SPIVAK MD

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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	259527	NY
2	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	52868	CT
3	207RP1001X	Pulmonary Disease Physician	259527	NY
4	207RP1001X	Pulmonary Disease Physician	52868	CT

General Provider Information

NPI Number	:	1780889493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROMAN SPIVAK MD

Provider Business Mailing Address
First Line	:	67 MAPLE AVE
Second Line	:
City	:	DERBY
State	:	CT
Zip	:	06418-1328
Country	:	US
Telephone Number	:	203-732-1330
Fax Number	:	203-732-1332

Provider Business Practice Location Address
First Line	:	135 DIVISION ST STE 2
Second Line	:
City	:	ANSONIA
State	:	CT
Zip	:	06401-2135
Country	:	US
Telephone Number	:	203-308-2705
Fax Number	:	203-734-0137

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

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	10/12/2018

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Directions to “ DR. ROMAN SPIVAK MD” Practice Location

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