Provider Demographics
NPI:1144401670
Name:BARRY SLOTKY, M.D., S.C.
Entity Type:Organization
Organization Name:BARRY SLOTKY, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SLOTKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-663-6338
Mailing Address - Street 1:107 N REGENCY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3515
Mailing Address - Country:US
Mailing Address - Phone:309-663-6338
Mailing Address - Fax:309-661-5644
Practice Address - Street 1:107 N REGENCY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3515
Practice Address - Country:US
Practice Address - Phone:309-663-6338
Practice Address - Fax:309-661-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047218207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty