=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154457125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE STEPHEN SPICER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 03/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 MADISON AVE FL 10B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-2820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-479-8400
-----------------------------------------------------
Fax | 917-522-9654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 MADISON AVE FL 10B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-2820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-479-8400
-----------------------------------------------------
Fax | 917-522-9654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 60-239421
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------