Basic Information
| Provider Information | |||||||||
| NPI: | 1740245208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLAVENS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TEDFORD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232832 | ||||||||
| FaxNumber: | 7722235646 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 S KANNER HWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349944801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722194026 | ||||||||
| FaxNumber: | 7722834919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME93774 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 28685 | 01 | FL | BLUE SHIELD OF FL PROV # | OTHER | 273640300 | 05 | FL | MEDICAID |