Basic Information
Provider Information | |||||||||
NPI: | 1275559163 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPISAK | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WYLIE | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 102 HANDLEY PARK CT | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275341768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197343344 | ||||||||
FaxNumber: | 9197353025 | ||||||||
Practice Location | |||||||||
Address1: | 102 HANDLEY PARK CT | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275341768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197343344 | ||||||||
FaxNumber: | 9197353025 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 10/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301077897 | MI | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 2022-00284 | NC | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 160G360190 | 01 |   | BCBSM GROUP PIN | OTHER | 156058 | 01 |   | GREAT LAKES HEALTH PLAN | OTHER | 700G410560 | 01 | MI | BLUE CROSS | OTHER |