Provider Demographics
NPI:1952300725
Name:SPELLACY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SPELLACY
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 1:7287 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7287 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-1130
Practice Address - Country:US
Practice Address - Phone:814-877-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S008461L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA67788OtherUNISON
NY01871567OtherNY MEDICAID
OH2226924OtherOH MEDICAID
NY00025875001OtherUNIVERA
PA080091229OtherRR MEDICARE
PA865315OtherBLUE SHIELD
PAP000492OtherGATEWAY
PA562439OtherAETNA
PA212686OtherUPMC
PA0015856720006Medicaid
PA67788OtherUNISON
NY00025875001OtherUNIVERA