Provider Demographics
NPI:1548375637
Name:SLACK, KENNETH DALE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DALE
Last Name:SLACK
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:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-339-1166
Practice Address - Fax:573-339-7166
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017031964207V00000X
NMMD2003-0686174400000X
CO44508207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM41035259Medicaid
CO86081039Medicaid
COC808097Medicare PIN
NMG90888Medicare UPIN
COCO306888Medicare PIN
CO86081039Medicaid