Provider Demographics
NPI:1255465720
Name:JESSICA SPAYD
Entity Type:Organization
Organization Name:JESSICA SPAYD
Other - Org Name:EAGLE RIVER PAIN & WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPAYD
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-622-4673
Mailing Address - Street 1:11823 OLD GLENN HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7734
Mailing Address - Country:US
Mailing Address - Phone:907-622-4673
Mailing Address - Fax:907-622-4674
Practice Address - Street 1:11823 OLD GLENN HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7734
Practice Address - Country:US
Practice Address - Phone:907-622-4673
Practice Address - Fax:907-622-4674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4245, 677, 20608207Q00000X, 207QA0401X, 207QS0010X, 208100000X, 2081P2900X, 208D00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD42453Medicaid
AKNP9295Medicaid
1386602019OtherANP SPAYD NPI
1326187055OtherDR. HEROLD'S NPI
AKNP9295Medicaid
AKMD42453Medicaid
AKK152741Medicare ID - Type UnspecifiedINDIVID ID
AKNP9295Medicaid
AKK152739Medicare PIN
AKP60055Medicare UPIN