Healthcare Provider Details

I. General information

NPI: 1932429602
Provider Name (Legal Business Name): MELANIE PATRICE SLACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS MELANIE PATRICE KOLPAK

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1694 WATER TOWER WAY STE 104
FOREST HILL MD
21050-1776
US

IV. Provider business mailing address

1694 WATER TOWER WAY STE 104
FOREST HILL MD
21050-1776
US

V. Phone/Fax

Practice location:
  • Phone: 410-307-4568
  • Fax: 949-703-7304
Mailing address:
  • Phone: 410-307-4568
  • Fax: 949-703-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC7-0004578
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0010354
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDS0080767
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: