Provider Demographics
NPI:1578593398
Name:SPICER, STEPHANIE E (DPM)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:SPICER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19900 GOVERNORS DR STE 102
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1060
Mailing Address - Country:US
Mailing Address - Phone:708-957-3338
Mailing Address - Fax:708-856-0340
Practice Address - Street 1:19900 GOVERNORS DR STE 102
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461
Practice Address - Country:US
Practice Address - Phone:708-957-3338
Practice Address - Fax:708-856-0340
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004673213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004673Medicaid
IL01626972OtherBCBS
IL4024810001OtherDMERC
ILP00080285OtherRAILROAD MEDICARE
IL01626972OtherBCBS
ILK49603Medicare PIN