Healthcare Provider Details

I. General information

NPI: 1578873709
Provider Name (Legal Business Name): JOSEPH W SLATTERY III MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S WICKHAM RD SUITE 101
WEST MELBOURNE FL
32904-1428
US

IV. Provider business mailing address

630 S WICKHAM RD SUITE 101
WEST MELBOURNE FL
32904-1428
US

V. Phone/Fax

Practice location:
  • Phone: 321-952-9993
  • Fax:
Mailing address:
  • Phone: 321-952-9993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME63360
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME63360
License Number StateFL

VIII. Authorized Official

Name: MRS. BRETT MEEHAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 321-952-9993