Healthcare Provider Details

I. General information

NPI: 1750672481
Provider Name (Legal Business Name): JASON BRYANT SLADE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 ST LUKES DR
NAMPA ID
83687-7912
US

IV. Provider business mailing address

705 RILEY HOSPITAL DR RM 5867
INDIANAPOLIS IN
46202-5109
US

V. Phone/Fax

Practice location:
  • Phone: 208-505-5200
  • Fax:
Mailing address:
  • Phone: 217-819-2137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-12906
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-12906
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: