Provider Demographics
NPI:1588758940
Name:SLACK, MICHAEL C (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:SLACK
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 62063
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2063
Mailing Address - Country:US
Mailing Address - Phone:410-706-5181
Mailing Address - Fax:410-706-5103
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:N5W70C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-2427
Practice Address - Fax:443-462-3137
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD318602080P0202X
MDD553802080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC028095100Medicaid
MD202009201Medicaid
DC0614OtherCAREFIRST
MD202009200Medicaid
VA6731538Medicaid
F83329Medicare UPIN
010842C95Medicare ID - Type Unspecified
VA6731538Medicaid