Healthcare Provider Details

I. General information

NPI: 1356558464
Provider Name (Legal Business Name): MICHAEL JOSEF SLIMACK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 104TH AVE SUITE 110
KENOSHA WI
53142-7845
US

IV. Provider business mailing address

7401 104TH AVE SUITE 110
KENOSHA WI
53142-7845
US

V. Phone/Fax

Practice location:
  • Phone: 262-764-5595
  • Fax: 262-764-9314
Mailing address:
  • Phone: 262-764-5595
  • Fax: 262-764-9314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number58000956
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number51760
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: