Basic Information
| Provider Information | |||||||||
| NPI: | 1205895554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLACK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8019 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011028000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664314077 | ||||||||
| FaxNumber: | 4137747448 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 NORTHAMPTON ST | ||||||||
| Address2: | #H | ||||||||
| City: | EASTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010271057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135299300 | ||||||||
| FaxNumber: | 4135279793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 72497 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 72497 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 16474 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 2358373 | 01 | MA | AETNA | OTHER | 740008 | 01 | MA | CONNECTICARE | OTHER | J09911 | 01 | MA | BCBSMA | OTHER | 000000007738 | 01 | MA | BOSTON MEDICAL CENTER HEALTHNET PLAN | OTHER | 1293916 | 01 | MA | FALLON | OTHER | 3066134 | 05 | MA | MEDICAID | 1024130 | 01 | MA | CIGNA | OTHER | 63401 | 01 | MA | HARVARD PILGRIM | OTHER | 729533 | 01 | MA | TUFTS | OTHER |