MEDICARE: MRS. MADILYN SUE SLADE PT

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	225100000X	Physical Therapist	6903	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	68-0659242	OTHER	AZ	TAX ID
2	6903	OTHER	AZ	LICENSE

General Provider Information

NPI Number	:	1740488675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MADILYN SUE SLADE PT

Provider Business Mailing Address
First Line	:	1118 N RECKER RD
Second Line	:	109
City	:	MESA
State	:	AZ
Zip	:	85205-5504
Country	:	US
Telephone Number	:	480-833-2778
Fax Number	:	480-833-0232

Provider Business Practice Location Address
First Line	:	1118 N RECKER RD
Second Line	:	109
City	:	MESA
State	:	AZ
Zip	:	85205-5504
Country	:	US
Telephone Number	:	480-833-2778
Fax Number	:	480-833-0232

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

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	11/03/2014

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Directions to “ MRS. MADILYN SUE SLADE PT” Practice Location

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