Provider Demographics
NPI:1619048204
Name:LOWRY, SLATER BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:SLATER
Middle Name:BENJAMIN
Last Name:LOWRY
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 1:362 PARK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1326
Mailing Address - Country:US
Mailing Address - Phone:662-244-8864
Mailing Address - Fax:662-244-8874
Practice Address - Street 1:362 PARK CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1324
Practice Address - Country:US
Practice Address - Phone:662-244-8864
Practice Address - Fax:662-244-8874
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11050207R00000X
AL00013753207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL73003895OtherALABAMA LICENSE #
MS11050OtherMS LICENSE #
MS25D0981538OtherCLIA
MS640933050OtherTAX ID
MS00119201Medicaid
MS11050OtherMS LICENSE #
MSC70208Medicare UPIN