Provider Demographics
NPI:1700808896
Name:SPIVACK, JORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
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 1:495 HIGHLANDS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COATSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320
Mailing Address - Country:US
Mailing Address - Phone:610-384-9500
Mailing Address - Fax:610-384-3998
Practice Address - Street 1:495 HIGHLANDS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COATSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320
Practice Address - Country:US
Practice Address - Phone:610-384-9500
Practice Address - Fax:610-384-3998
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-073869-L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH60967Medicare UPIN
PA058000Medicare ID - Type Unspecified