Provider Demographics
NPI:1497850341
Name:SLATTERY, ELISABETH A (MD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:A
Last Name:SLATTERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:225 SMITH AVE N STE 300
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2592
Practice Address - Country:US
Practice Address - Phone:651-241-5000
Practice Address - Fax:651-241-5511
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31392207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN830G1SLOtherBCBS
MN0408095OtherMEDICA
WI31465300Medicaid
MNNA2351019583OtherPREFERREDONE
MN140132OtherUCARE
MN938088400Medicaid
MNHP31074OtherHEALTHPARTNERS
MN110010872Medicare PIN
B58414Medicare UPIN
MN830G1SLOtherBCBS
MN140132OtherUCARE