Provider Demographics
NPI:1598803785
Name:SPEELMAN, ELMER J (CPO)
Entity Type:Individual
Prefix:MR
First Name:ELMER
Middle Name:J
Last Name:SPEELMAN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5576
Mailing Address - Country:US
Mailing Address - Phone:910-286-6306
Mailing Address - Fax:910-483-9622
Practice Address - Street 1:435 W RUSSELL ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5576
Practice Address - Country:US
Practice Address - Phone:910-286-6306
Practice Address - Fax:910-483-9622
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7795083222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000024Medicaid
NC7795083Medicaid