Basic Information
| Provider Information | |||||||||
| NPI: | 1598084451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPARE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 WALNUT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159552243 | ||||||||
| FaxNumber: | 2159552060 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 WALNUT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159552243 | ||||||||
| FaxNumber: | 2159552060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | OS016754 | PA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2084N0400X | OS016754 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.