Healthcare Provider Details

I. General information

NPI: 1124220090
Provider Name (Legal Business Name): GWYNETH ANNE SPAEDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GWYNETH ANNE SUSIL MD

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10831 FOREST PINES DR STE 100
RALEIGH NC
27614-8077
US

IV. Provider business mailing address

2000 PERIMETER PARK DR STE 200
MORRISVILLE NC
27560-8442
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-5273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014-01880
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20400
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: