Provider Demographics
NPI:1679508618
Name:SLACK, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:SLACK
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 1:3100 SPRING FOREST RD
Mailing Address - Street 2:STE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-7908
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:8700 SUDLEY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4418
Practice Address - Country:US
Practice Address - Phone:703-369-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044713207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010094291Medicaid
VA191639OtherANTHEM
VA003569L92Medicare ID - Type Unspecified
VAE53265Medicare UPIN