MEDICARE: SPARK TMS THERAPEUTIC CENTER, LLC

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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1982172094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARK TMS THERAPEUTIC CENTER, LLC

Provider Business Mailing Address
First Line	:	128 CHESTNUT ST STE 103
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-3024
Country	:	US
Telephone Number	:	484-278-1616
Fax Number	:

Provider Business Practice Location Address
First Line	:	128 CHESTNUT ST STE 103
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-3024
Country	:	US
Telephone Number	:	484-278-1616
Fax Number	:	215-356-1700

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. ANDREW PESHEK
Credential	:
Telephone Number	:	267-307-2340

Provider Enumeration Date	:	11/06/2018
Last Update Date	:	04/12/2023

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