Provider Demographics
NPI:1922129352
Name:MARK SLAUGHTER PC
Entity Type:Organization
Organization Name:MARK SLAUGHTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAUGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:P T
Authorized Official - Phone:618-656-5433
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06032038OtherBLUE CROSS BLUE SHIELD
IL4650113OtherAETNA
IL514168OtherHEALTHLINK
MO167276OtherBLUE CROSS BLUE SHIELD
IL64-00479OtherUNITED HEALTHCARE
MO167276OtherBLUE CROSS BLUE SHIELD
IL514168OtherHEALTHLINK