MEDICARE: DR. CHRISTOPHER LEE 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	207YS0123X	Facial Plastic Surgery Physician	ME84369	FL
2	207YS0123X	Facial Plastic Surgery Physician	36380	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982613717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISTOPHER LEE SLACK M.D.

Provider Business Mailing Address
First Line	:	4632 S 25TH ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-5057
Country	:	US
Telephone Number	:	772-464-9595
Fax Number	:	772-464-9582

Provider Business Practice Location Address
First Line	:	4632 S 25TH ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-5057
Country	:	US
Telephone Number	:	772-464-9595
Fax Number	:	772-464-9582

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/09/2010

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