Provider Demographics
NPI:1134152382
Name:SLATER, DOUGLAS HARLEY (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:HARLEY
Last Name:SLATER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-7074
Mailing Address - Country:US
Mailing Address - Phone:989-348-0550
Mailing Address - Fax:989-348-6749
Practice Address - Street 1:1250 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-7074
Practice Address - Country:US
Practice Address - Phone:989-348-0550
Practice Address - Fax:989-348-6749
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406865207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2982265Medicaid
MI3389713Medicaid
MI4120160Medicaid
M55010003Medicare PIN
MI2982265Medicaid
M65990001Medicare PIN
B06000036Medicare PIN