Basic Information
| Provider Information | |||||||||
| NPI: | 1609547173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPAK | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 OAKWOOD HILLS DR APT 307 | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170555917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146591160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 503 N 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170112204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177632100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2021 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | MA062667 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.