1760467492 NPI number — DR. ROBERT STEVEN SLACK MD

Table of content: DR. ROBERT STEVEN SLACK MD (NPI 1760467492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760467492 NPI number — DR. ROBERT STEVEN SLACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLACK
Provider First Name:
ROBERT
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760467492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CMR 427
Provider Second Line Business Mailing Address:
BOX 2278
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
393351201124
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LANDSTUHL REGIONAL MEDICAL CENTER
Provider Second Line Business Practice Location Address:
ATTN MCEUL DCCS (CREDENTIALS), CMR 402
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
011496371868839
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2005

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: 207R00000X , with the licence number:  A52230 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RC0200X , with the licence number: A52230 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RP1001X , with the licence number: A52230 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CAL A52230 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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