MEDICARE: CHARLES THORNTON SLACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	J0267	TX

General Provider Information

NPI Number	:	1720038151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES THORNTON SLACK M.D.

Provider Business Mailing Address
First Line	:	1405 PECAN HOLLOW TRL
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75070-9061
Country	:	US
Telephone Number	:	972-562-7253
Fax Number	:	214-509-0273

Provider Business Practice Location Address
First Line	:	1105 CENTRAL EXPY NORTH
Second Line	:	SUITE 370
City	:	ALLEN
State	:	TX
Zip	:	75013
Country	:	US
Telephone Number	:	214-495-6464
Fax Number	:	214-509-0273

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	04/23/2013

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