Healthcare Provider Details

I. General information

NPI: 1841275179
Provider Name (Legal Business Name): ANGELA SMITH-SLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 GOODWIN ROAD
CHATTANOOGA TN
37421
US

IV. Provider business mailing address

1949 GUNBARREL ROAD SUITE 230
CHATTANOOGA TN
37421
US

V. Phone/Fax

Practice location:
  • Phone: 423-894-3252
  • Fax: 423-894-2237
Mailing address:
  • Phone: 423-495-3671
  • Fax: 423-495-4934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28286
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: