Provider Demographics
NPI:1437129582
Name:SPEELMAN, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:SPEELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 E WASHINGTON ST
Mailing Address - Street 2:SUITE 4 B
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3332
Mailing Address - Country:US
Mailing Address - Phone:330-723-3256
Mailing Address - Fax:330-722-6731
Practice Address - Street 1:970 E WASHINGTON ST
Practice Address - Street 2:SUITE 4 B
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3332
Practice Address - Country:US
Practice Address - Phone:330-723-3256
Practice Address - Fax:330-722-6731
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35036382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0480840Medicaid
OH720OtherSUMMA
OH000000129521OtherANTHEM
OH791083847OtherRAILROAD MEDICARE
OH53453OtherQUALCHOICE
OH0462534Medicare ID - Type Unspecified
OH0480840Medicaid