Healthcare Provider Details

I. General information

NPI: 1619548658
Provider Name (Legal Business Name): TRIENT BOYD SPIRES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD DEPT GME
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

5501 OLD YORK RD DEPT GME
PHILADELPHIA PA
19141-3018
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-7890
  • Fax:
Mailing address:
  • Phone: 215-456-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOT021479
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: