Provider Demographics
NPI:1972513083
Name:SPELICH, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SPELICH
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 1:7979 W. RIFLEMAN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-855-2410
Mailing Address - Fax:208-855-0157
Practice Address - Street 1:7979 W RIFLEMAN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9066
Practice Address - Country:US
Practice Address - Phone:208-855-2410
Practice Address - Fax:208-855-0157
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9278207X00000X
ORMD25792207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
74880OtherBX
000010151179OtherREG
ID807210200Medicaid
I37201Medicare UPIN
1131204Medicare ID - Type Unspecified