Healthcare Provider Details

I. General information

NPI: 1588758940
Provider Name (Legal Business Name): MICHAEL C SLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST N5W70C
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 62063
BALTIMORE MD
21264-2063
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2427
  • Fax: 443-462-3137
Mailing address:
  • Phone: 410-706-5181
  • Fax: 410-706-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD31860
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberD55380
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: