Healthcare Provider Details

I. General information

NPI: 1639113095
Provider Name (Legal Business Name): PHILIP T. SLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 JESSE JEWELL PKWY NE STE 300
GAINESVILLE GA
30501-3822
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-6520
  • Fax: 770-219-1016
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number035523
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number035523
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: