1912009739 NPI number — MR. MARK S SLAUGHTER PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912009739 NPI number — MR. MARK S SLAUGHTER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLAUGHTER
Provider First Name:
MARK
Provider Middle Name:
S
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1912009739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 2ND AVE.
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
EDWARDSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62025-2556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-656-5433
Provider Business Mailing Address Fax Number:
618-656-5437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
219 2ND AVE.
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62025-2556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-656-5433
Provider Business Practice Location Address Fax Number:
618-656-5437
Provider Enumeration Date:
09/02/2006

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: 225100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06032038 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00019088 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 4650113 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 167276 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 514168 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 6400479 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com