Provider Demographics
NPI:1558850164
Name:SPENCER, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-299-2450
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 407
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-335-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99086926A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300014870Medicaid