MEDICARE: ANDREA SPIVACK MA, RD, LDN

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	133V00000X	Registered Dietitian	DN003746	PA

General Provider Information

NPI Number	:	1952757106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA SPIVACK MA, RD, LDN

Provider Business Mailing Address
First Line	:	3535 MARKET ST
Second Line	:	MEZZANINE LEVEL/STUNKARD PRGRAM
City	:	PHILA
State	:	PA
Zip	:	19104
Country	:	US
Telephone Number	:	215-746-4112
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 MARKET ST
Second Line	:	MEZZANINE/STUNAKRD PROGRAM
City	:	PHILA
State	:	PA
Zip	:	19444
Country	:	US
Telephone Number	:	215-746-4112
Fax Number	:

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

Provider Enumeration Date	:	05/06/2016
Last Update Date	:	05/23/2016

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