Provider Demographics
NPI:1073573572
Name:SPACK, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SPACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 SOUTH DIVISION STREET
Mailing Address - Street 2:UNIT 401, PENINSULA UROLOGY ASSOCIATES PA
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21084
Mailing Address - Country:US
Mailing Address - Phone:410-546-2133
Mailing Address - Fax:410-548-3361
Practice Address - Street 1:1342 SOUTH DIVISION STREET
Practice Address - Street 2:UNIT 401, PENINSULA UROLOGY ASSOCIATES PA
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21084
Practice Address - Country:US
Practice Address - Phone:410-546-2133
Practice Address - Fax:410-548-3361
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0001119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH831Medicare ID - Type Unspecified