Provider Demographics
NPI:1407900335
Name:SLIPKOVICH, RICHARD G (PA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:G
Last Name:SLIPKOVICH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:211 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2721
Mailing Address - Country:US
Mailing Address - Phone:770-507-4554
Mailing Address - Fax:770-507-6413
Practice Address - Street 1:211 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2721
Practice Address - Country:US
Practice Address - Phone:770-507-4554
Practice Address - Fax:770-507-6413
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA220269127AMedicaid
GA511I970050Medicare PIN