Provider Demographics
NPI:1649266180
Name:SPICER, STEPHEN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CHARLES
Last Name:SPICER
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:1103 E GRACE ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3210
Practice Address - Country:US
Practice Address - Phone:219-866-4135
Practice Address - Fax:219-866-0803
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INA01021575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1002919620Medicaid
IN791083372OtherPALMETTO GBA
IN100219620AMedicaid
IN100219620AMedicaid
INB29374Medicare UPIN
INB29374Medicare UPIN