Provider Demographics
NPI:1740243575
Name:SLUDER, COLLEEN MARY (DO)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:SLUDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3381 PHILLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1560
Mailing Address - Country:US
Mailing Address - Phone:843-477-0177
Mailing Address - Fax:
Practice Address - Street 1:3381 PHILLIS BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1560
Practice Address - Country:US
Practice Address - Phone:843-477-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0061487207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405309500Medicaid
MD405309500Medicaid
MDI10799Medicare UPIN