Healthcare Provider Details

I. General information

NPI: 1588688147
Provider Name (Legal Business Name): JEANETTE K SLADICK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD TRAUMA SERVICES
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-5440
  • Fax: 313-982-5445
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10112
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005370
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: