Basic Information
| Provider Information | |||||||||
| NPI: | 1437129582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPEELMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 970 E WASHINGTON ST | ||||||||
| Address2: | SUITE 4 B | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307233256 | ||||||||
| FaxNumber: | 3307226731 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 E WASHINGTON ST | ||||||||
| Address2: | SUITE 4 B | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307233256 | ||||||||
| FaxNumber: | 3307226731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 04/05/2010 | ||||||||
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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 | 207Q00000X | 35036382 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0480840 | 05 | OH | MEDICAID | 720 | 01 | OH | SUMMA | OTHER | 000000129521 | 01 | OH | ANTHEM | OTHER | 791083847 | 01 | OH | RAILROAD MEDICARE | OTHER | 53453 | 01 | OH | QUALCHOICE | OTHER |