Provider Demographics
NPI:1275822918
Name:SLACK, ADELAIDE ROBINSON (MD)
Entity Type:Individual
Prefix:MRS
First Name:ADELAIDE
Middle Name:ROBINSON
Last Name:SLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:ADELAIDE
Other - Middle Name:HILL
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4745 S 3200 W
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-2822
Mailing Address - Country:US
Mailing Address - Phone:801-858-3461
Mailing Address - Fax:801-955-2389
Practice Address - Street 1:1388 S NAVAJO ST
Practice Address - Street 2:SUITE C
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-3493
Practice Address - Country:US
Practice Address - Phone:801-955-2360
Practice Address - Fax:801-982-9232
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51664207Q00000X
UT9429781-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine