1275822918 NPI number — MRS. ADELAIDE ROBINSON SLACK MD

Table of content: MRS. ADELAIDE ROBINSON SLACK MD (NPI 1275822918)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275822918 NPI number — MRS. ADELAIDE ROBINSON SLACK MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
SLACK

Provider First Name:
ADELAIDE

Provider Middle Name:
ROBINSON

Provider Name Prefix Text:
MRS.

Provider Name Suffix Text:

Provider Credential Text:
MD

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
ROBINSON

Provider Other First Name:
ADELAIDE

Provider Other Middle Name:
HILL

Provider Other Name Prefix Text:
MS.

Provider Other Name Suffix Text:

Provider Other Credential Text:
MD

Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275822918

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
08/03/2015

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4745 S 3200 W

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
TAYLORSVILLE

Provider Business Mailing Address State Name:
UT

Provider Business Mailing Address Postal Code:
84129-2822

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
801-858-3461

Provider Business Mailing Address Fax Number:
801-955-2389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1388 S NAVAJO ST

Provider Second Line Business Practice Location Address:
SUITE C

Provider Business Practice Location Address City Name:
SALT LAKE CITY

Provider Business Practice Location Address State Name:
UT

Provider Business Practice Location Address Postal Code:
84104-3493

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
801-955-2360

Provider Business Practice Location Address Fax Number:
801-982-9232

Provider Enumeration Date:
04/04/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 207Q00000X , with the licence number: 51664 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 207Q00000X , with the licence number: 9429781-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .