Basic Information
Provider Information | |||||||||
NPI: | 1639193626 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SLAUTERBECK | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40480 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366400480 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514343626 | ||||||||
FaxNumber: | 2514452464 | ||||||||
Practice Location | |||||||||
Address1: | 1601 CENTER ST | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366041541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516658200 | ||||||||
FaxNumber: | 2516658210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2006 | ||||||||
LastUpdateDate: | 03/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 42-0010895 | VT | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | 42-0010895 | VT | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | MD.41721 | AL | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 02623747 | 01 | NY | NY MEDICAID | OTHER | 1011138 | 05 | VT |   | MEDICAID |