Individual
MARK R SLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
8700 SUDLEY RD, MANASSAS, VA 20110-4418
(703) 369-8000
Mailing address
3100 SPRING FOREST RD, STE 130, RALEIGH, NC 27616-2880
(919) 882-7908
(919) 873-9821
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
0101044713
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010094291
—
VA
01
—
191639
ANTHEM
VA
Enumeration date
07/11/2006
Last updated
02/15/2017
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