Provider Demographics
NPI:1518900190
Name:SPIVACK, PAUL S (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:SPIVACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6708
Mailing Address - Country:US
Mailing Address - Phone:603-695-2572
Mailing Address - Fax:603-695-2727
Practice Address - Street 1:25 S RIVER RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6708
Practice Address - Country:US
Practice Address - Phone:603-695-2572
Practice Address - Fax:603-695-2727
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7629208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30001972Medicaid
NHNH9448Medicare PIN
C66048Medicare UPIN