Provider Demographics
NPI:1588924328
Name:SLADE, JAMIE (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:SLADE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-5471
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-28
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125060915207ZP0102X
IL036.138057207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology