Provider Demographics
NPI:1548370570
Name:SPICKLEMIRE, KENNETH M (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:SPICKLEMIRE
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-232-3281
Mailing Address - Fax:812-235-3758
Practice Address - Street 1:4601 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4522
Practice Address - Country:US
Practice Address - Phone:812-232-3281
Practice Address - Fax:812-235-3758
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028691A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100250990RMedicaid
000000089619OtherANTHEM
IN100250990Medicaid
INP00834942OtherRAILROAD MEDICARE
080000130OtherRAILROAD MCARE PALAMETTO
IN100250990QMedicaid
IN192770MMMMedicare PIN
080000130OtherRAILROAD MCARE PALAMETTO
INP00834942OtherRAILROAD MEDICARE
IN265130ZZZMedicare PIN
IN187850BMedicare PIN