Provider Demographics
NPI:1912009739
Name:SLAUGHTER, MARK S (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:SLAUGHTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 2ND AVE.
Mailing Address - Street 2:SUITE C
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2556
Mailing Address - Country:US
Mailing Address - Phone:618-656-5433
Mailing Address - Fax:618-656-5437
Practice Address - Street 1:219 2ND AVE.
Practice Address - Street 2:SUITE C
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2556
Practice Address - Country:US
Practice Address - Phone:618-656-5433
Practice Address - Fax:618-656-5437
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06032038OtherBLUE CROSS BLUE SHIELD
ILP00019088OtherRAILROAD MEDICARE
IL4650113OtherAETNA
MO167276OtherBLUE CROSS BLUE SHIELD
IL514168OtherHEALTHLINK
IL6400479OtherUNITED HEALTHCARE
ILK47308Medicare PIN