Provider Demographics
NPI:1558316893
Name:SLACK, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD STE 300
Mailing Address - Street 2:ATTN: RAQUEL LEON
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:
Practice Address - Street 1:150 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7553
Practice Address - Country:US
Practice Address - Phone:312-444-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-048353207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-048353Medicaid
ILK32489Medicare PIN
ILC42514Medicare UPIN
ILK32488Medicare PIN