Provider Demographics
NPI:1598744724
Name:SLOG, MARIA (PA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:SLOG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 POND RD
Mailing Address - Street 2:STE 203
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-2254
Mailing Address - Country:US
Mailing Address - Phone:610-366-1366
Mailing Address - Fax:
Practice Address - Street 1:1575 POND RD
Practice Address - Street 2:STE 203
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-2254
Practice Address - Country:US
Practice Address - Phone:610-366-1366
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003124L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ42678Medicare UPIN