Basic Information
| Provider Information | |||||||||
| NPI: | 1548370570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPICKLEMIRE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122323281 | ||||||||
| FaxNumber: | 8122353758 | ||||||||
| Practice Location | |||||||||
| Address1: | 4601 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478024522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122323281 | ||||||||
| FaxNumber: | 8122353758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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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 | 01028691A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100250990R | 05 | IN | MEDICAID | 000000089619 | 01 | ANTHEM | OTHER | 100250990 | 05 | IN | MEDICAID | P00834942 | 01 | IN | RAILROAD MEDICARE | OTHER | 080000130 | 01 | RAILROAD MCARE PALAMETTO | OTHER | 100250990Q | 05 | IN | MEDICAID |