Provider Demographics
NPI:1578748315
Name:BLAKE M SLATER D O P C
Entity Type:Organization
Organization Name:BLAKE M SLATER D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D O
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SLATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-484-2295
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49719-0630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:391 EAST HIGHWAY M-134
Practice Address - Street 2:POB 630
Practice Address - City:CEDARVILLE
Practice Address - State:MI
Practice Address - Zip Code:49719-0630
Practice Address - Country:US
Practice Address - Phone:906-484-2295
Practice Address - Fax:906-484-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI007998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1779863Medicaid
MIP08230001Medicare PIN
MI0P08230Medicare PIN
MIE25573Medicare UPIN
MI1779863Medicaid
MI507651Medicare UPIN