Provider Demographics
NPI:1609877158
Name:SLATTERY, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SLATTERY
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 1:821 CLIFF ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-2097
Mailing Address - Country:US
Mailing Address - Phone:607-277-2365
Mailing Address - Fax:607-277-1415
Practice Address - Street 1:8 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1871
Practice Address - Country:US
Practice Address - Phone:607-273-6757
Practice Address - Fax:607-273-2854
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2207402084S0012X, 2084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02136987Medicaid
NY02136987Medicaid
NYJ400059301Medicare PIN
NYCC5655Medicare PIN