Provider Demographics
NPI:1710993159
Name:SPECTRUM HEALTHCARE PARTNERS, PA
Entity Type:Organization
Organization Name:SPECTRUM HEALTHCARE PARTNERS, PA
Other - Org Name:SPECTRUM MEDICAL GROUP, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-883-5295
Mailing Address - Street 1:PO BOX 95000 LB#7810
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:844-947-4259
Mailing Address - Fax:302-261-8368
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-8305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM HEALTHCARE PARTNERS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-31
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1710993159Medicaid
ME130560050Medicaid
ME130560060Medicaid
ME130560066Medicaid
ME130560069Medicaid
ME2547081OtherAETNA PHO
ME130560039Medicaid
ME130560043Medicaid
ME130560062Medicaid
ME2012941OtherAETNA
MES0529OtherANTHEM
ME130560004Medicaid
ME002OtherUNICARE
ME130560045Medicaid
ME130560049Medicaid
ME130560061Medicaid
ME130560040Medicaid
ME130560051Medicaid