MEDICARE: DR. SIMON DANIEL SPIVACK M.D.

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	189782-1	NY
2	207RP1001X	Pulmonary Disease Physician	189782-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366438475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SIMON DANIEL SPIVACK M.D.

Provider Business Mailing Address
First Line	:	1300 MORRIS PARK AVE
Second Line	:	PULMONARY MEDICINE
City	:	BRONX
State	:	NY
Zip	:	10461-1900
Country	:	US
Telephone Number	:	718-430-2591
Fax Number	:	718-430-8563

Provider Business Practice Location Address
First Line	:	1300 MORRIS PARK AVE
Second Line	:	PULMONARY MEDICINE
City	:	BRONX
State	:	NY
Zip	:	10461-1900
Country	:	US
Telephone Number	:	718-430-2591
Fax Number	:	718-430-8563

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

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	08/23/2007

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