Provider Demographics
NPI:1326034760
Name:SLAUGHTER, MARK SULLIVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SULLIVAN
Last Name:SLAUGHTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 ABRAHAM FLEXNER WAY
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3841
Mailing Address - Country:US
Mailing Address - Phone:502-561-2180
Mailing Address - Fax:502-561-2190
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 1200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3841
Practice Address - Country:US
Practice Address - Phone:502-561-2180
Practice Address - Fax:502-561-2190
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42157208G00000X
IL036075781208600000X, 208G00000X
IN01043482A208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200061040DMedicaid
IL036075781Medicaid
IN200061040CMedicaid
IN200061040AMedicaid
IN200061040EMedicaid
IL01618941OtherBCBS
IN200061040BMedicaid
IL338910Medicare PIN
ILK17072Medicare PIN
IL036075781Medicaid
IN780002106Medicare PIN
IN200061040BMedicaid
IL01618941OtherBCBS
IN200061040EMedicaid
IN200061040CMedicaid