Basic Information
| Provider Information | |||||||||
| NPI: | 1013169879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLACK | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | VERNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7727 LAKE UNDERHILL RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328228224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073036413 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7727 LAKE UNDERHILL RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328228224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073036413 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | TRN18079 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208600000X | 24792 | NE | N | Allopathic & Osteopathic Physicians | Surgery | 207P00000X | ME119973 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.