Healthcare Provider Details

I. General information

NPI: 1417151549
Provider Name (Legal Business Name): TALYA R SPIVACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 E EVESHAM RD STE 201A
VOORHEES NJ
08043-1559
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-325-5400
  • Fax: 856-325-5416
Mailing address:
  • Phone: 856-355-0340
  • Fax: 856-355-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD190814
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA09451900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: