Provider Demographics
NPI:1699858514
Name:SLADE, LANCE E (MD)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:E
Last Name:SLADE
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 1:550 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1411
Mailing Address - Country:US
Mailing Address - Phone:478-741-3007
Mailing Address - Fax:478-330-6288
Practice Address - Street 1:550 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1411
Practice Address - Country:US
Practice Address - Phone:478-741-3007
Practice Address - Fax:478-330-6288
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52488208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA318185311AMedicaid