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General NPI Number Information
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NPI Number | 1679006076
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Entity Type | Individual
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Provider Name | MICHAEL SLACK DO
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Gender | Male
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Dates
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Enumeration Date | 04/04/2017
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Last Update Date | 02/20/2024
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Provider Practice Location Address
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Address Line | 4815 CLEVELAND BLVD
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City | CALDWELL
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State | ID
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Zip | 83605-6501
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Country | US
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Telephone | 208-455-3545
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Fax | 208-454-9690
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Provider Business Mailing Address
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Address Line | 5111 N TRAVIS ST APT 221
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City | SHERMAN
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State | TX
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Zip | 75092-4073
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | O-1447
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | S3590
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License Number State | TX
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