Provider Demographics
NPI:1891763082
Name:SLAGLE, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SLAGLE
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 1:1 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2576
Mailing Address - Country:US
Mailing Address - Phone:309-671-8503
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF INTERNAL MEDICINE
Practice Address - Street 2:530 NE GLEN OAK
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086726207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086726Medicaid
ILIL01G3OtherJOHN DEERE
IL07215036OtherBCBS
IL036086726Medicaid
ILCA4079Medicare ID - Type UnspecifiedRR GROUP #
IL440000829Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL800880Medicare ID - Type UnspecifiedGROUP #
IL07215036OtherBCBS
IL639810Medicare ID - Type UnspecifiedMEDICARE