Provider Demographics
NPI:1205005931
Name:MICHAEL P. SPELLICY
Entity Type:Organization
Organization Name:MICHAEL P. SPELLICY
Other - Org Name:MP SPELLICY, O.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:SPELLICY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-824-3453
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:2730 ROUTE 12B
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346
Mailing Address - Country:US
Mailing Address - Phone:315-824-3453
Mailing Address - Fax:315-824-4301
Practice Address - Street 1:2730 ROUTE 12B
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346
Practice Address - Country:US
Practice Address - Phone:315-824-3453
Practice Address - Fax:315-824-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3797-1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00600977Medicaid
NY38472BMedicare PIN