Healthcare Provider Details

I. General information

NPI: 1790005981
Provider Name (Legal Business Name): DONALD F SLACK III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 NORTH CHARLES ST. PPE STE 441
TOWSON MD
21204
US

IV. Provider business mailing address

6565 NORTH CHARLES ST PPE STE 411
TOWSON MD
21204
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-3901
  • Fax: 443-849-3902
Mailing address:
  • Phone: 443-849-3901
  • Fax: 443-849-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD0080447
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberD0080447
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: