Provider Demographics
NPI:1578836003
Name:C. LAWRENCE SLADE, M.D., F.A.C.S., LLC
Entity Type:Organization
Organization Name:C. LAWRENCE SLADE, M.D., F.A.C.S., LLC
Other - Org Name:CLEMENT L. SLADE, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-756-9400
Mailing Address - Street 1:3635 S CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-2300
Mailing Address - Country:US
Mailing Address - Phone:386-756-9400
Mailing Address - Fax:386-756-4338
Practice Address - Street 1:3635 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2300
Practice Address - Country:US
Practice Address - Phone:386-756-9400
Practice Address - Fax:386-756-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40228174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD65450Medicare UPIN