Healthcare Provider Details

I. General information

NPI: 1124055058
Provider Name (Legal Business Name): LISA SPACEK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 CHESTNUT ST STE 1020
PHILADELPHIA PA
19107-4310
US

IV. Provider business mailing address

PO BOX 64264
BALTIMORE MD
21264-4264
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-7785
  • Fax: 215-923-9362
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD57907
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD433099
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: