Provider Demographics
NPI:1205895554
Name:SLACK, DAVID M (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:SLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 8019
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01102-8000
Mailing Address - Country:US
Mailing Address - Phone:866-431-4077
Mailing Address - Fax:413-774-7448
Practice Address - Street 1:179 NORTHAMPTON ST
Practice Address - Street 2:#H
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1057
Practice Address - Country:US
Practice Address - Phone:413-529-9300
Practice Address - Fax:413-527-9793
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA72497207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA16474OtherHEALTH NEW ENGLAND
MA2358373OtherAETNA
MA740008OtherCONNECTICARE
MAJ09911OtherBCBSMA
MA000000007738OtherBOSTON MEDICAL CENTER HEALTHNET PLAN
MA1293916OtherFALLON
MA3066134Medicaid
MA1024130OtherCIGNA
MA63401OtherHARVARD PILGRIM
MA729533OtherTUFTS
E65746Medicare UPIN
MAJ09911Medicare PIN