Provider Demographics
NPI:1346375417
Name:MARK A SPELICH MD PC
Entity Type:Organization
Organization Name:MARK A SPELICH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:SARICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-855-2410
Mailing Address - Street 1:6590 W NORWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-855-2410
Mailing Address - Fax:208-855-0157
Practice Address - Street 1:6590 W NORWOOD DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-855-2410
Practice Address - Fax:208-855-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9278207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID74880OtherBLUE CROSS OF IDAHO #
ID807210200Medicaid
ID000010151179OtherREGENCE BLUE SHIELD #
ID807210200Medicaid
ID5499920001Medicare NSC
ID74880OtherBLUE CROSS OF IDAHO #