MEDICARE: MRS. MIRA N SLIZOVSKY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD065630L	PA
2	208000000X	Pediatrics Physician	01094049A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235195116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIRA N SLIZOVSKY MD

Provider Business Mailing Address
First Line	:	PO BOX 781076
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1076
Country	:	US
Telephone Number	:	317-528-4800
Fax Number	:	317-865-1479

Provider Business Practice Location Address
First Line	:	915 SAGAMORE PKWY W
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-1443
Country	:	US
Telephone Number	:	765-463-5252
Fax Number	:	765-463-2289

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	10/07/2024

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