Basic Information
| Provider Information | |||||||||
| NPI: | 1649266180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPICER | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654491196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 E GRACE ST | ||||||||
| Address2: | |||||||||
| City: | RENSSELAER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479783210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198664135 | ||||||||
| FaxNumber: | 2198660803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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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 | A01021575 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1002919620 | 05 | IN | MEDICAID | 791083372 | 01 | IN | PALMETTO GBA | OTHER | 100219620A | 05 | IN | MEDICAID |