Basic Information
| Provider Information | |||||||||
| NPI: | 1417248113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EISENBERG | ||||||||
| FirstName: | SPENCER | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638008 | ||||||||
| FaxNumber: | 6077638019 | ||||||||
| Practice Location | |||||||||
| Address1: | 507 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137901810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638008 | ||||||||
| FaxNumber: | 6077638019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2011 | ||||||||
| LastUpdateDate: | 07/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 271528 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 271528 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04109766 | 05 | NY | MEDICAID |