Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 096224 | NY |
NPI | 1003918871 |
---|---|
Provider Name | Dr. Alice Slade |
First Address | Newburgh, NY 12550-3150 |
Second Address | Newburgh, NY 12550-3150 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
004-98664 | (05) | NY |
B79778 | (02) | NY |