Provider Demographics
NPI:1346215845
Name:SPEICHER, MARK PAUL (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:SPEICHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:HOSPITALIST DEPT
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-6622
Practice Address - Fax:607-763-5064
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213917208M00000X
PAOS009551L207R00000X
NY213917-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02052197Medicaid
PA0017620980002Medicaid
P00624424OtherRR MEDICARE
NY110221437OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
P00624424OtherRR MEDICARE
NYRB6688Medicare PIN
NYCC5732Medicare PIN
NYJ400077032Medicare PIN