Provider Demographics
NPI:1285628909
Name:SPITALNICK, BENJAMIN D (MD)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:D
Last Name:SPITALNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4600 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6274
Mailing Address - Country:US
Mailing Address - Phone:912-355-2462
Mailing Address - Fax:912-353-1836
Practice Address - Street 1:4600 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6702
Practice Address - Country:US
Practice Address - Phone:912-355-2462
Practice Address - Fax:912-353-1836
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046910208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000865048AMedicaid
GA58-1102392OtherTAX ID #
SCG46910OtherSC MEDICAID
GA046910OtherSTATE LICENSE
GA046910OtherSTATE LICENSE
GA046910OtherSTATE LICENSE