Provider Demographics
NPI:1639703192
Name:SPIRIT SOARING MEDICAL PLLC
Entity Type:Organization
Organization Name:SPIRIT SOARING MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-564-8011
Mailing Address - Street 1:2761 JOHNSON HILL RD
Mailing Address - Street 2:
Mailing Address - City:SWAIN
Mailing Address - State:NY
Mailing Address - Zip Code:14884-9707
Mailing Address - Country:US
Mailing Address - Phone:607-564-8011
Mailing Address - Fax:
Practice Address - Street 1:2761 JOHNSON HILL RD
Practice Address - Street 2:
Practice Address - City:SWAIN
Practice Address - State:NY
Practice Address - Zip Code:14884-9707
Practice Address - Country:US
Practice Address - Phone:607-564-8011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty