NPIMap

Individual provider Active NPI

Michael Slack, DO

  • Family Medicine Physician
  • Caldwell, ID
National Provider Identifier
1679006076
Registry record updated Feb 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
O-1447 Issued in ID
Practice address
4815 Cleveland Blvd
Caldwell, ID 83605-6501
Phone
(208) 455-3545
Fax
(208) 454-9690
NPI assigned
Apr 4, 2017
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 20, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X O-1447 ID Primary
Family Medicine Physician 207Q00000X S3590 TX

Addresses

Primary practice location

4815 Cleveland Blvd
Caldwell, ID 83605-6501

Mailing address

5111 N Travis St Apt 221
Sherman, TX 75092-4073

Other practice location 1

5016 N US Hwy 75
Denison, TX 75020
Phone (903) 416-4000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20210628001079 ID Practitioner - Family Practice 6507296787 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Alliance Medical Group LLCGroup PAC ID 3971544685, 132 clinicians

Practice addresses (Care Compare)

4815 Cleveland Blvd
Caldwell, ID 83605-6501
Phone (208) 455-3545

Hospital & facility affiliations

  • St Luke'S Regional Medical Center Hospital, Boise, ID, CCN 130006
  • Saint Alphonsus Regional Medical Center Hospital, Boise, ID, CCN 130007
  • St Luke'S Nampa Medical Center Hospital, Nampa, ID, CCN 130071

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
S3590TXMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Alliance Medical Group, LLC Family Medicine CurrentSince Jul 19, 2021 Accepting new patients
Alliance Medical Group, LLC Family Medicine Current Accepting new patients
Alliance Medical Group, LLC Family Medicine Past Accepting new patients

Locations

4815 Cleveland Blvd
Caldwell, ID 83605
Phone (208) 455-3545

10482 W Carlton Bay Dr
Garden City, ID 83714
Phone (208) 454-9690

Interoperability endpoints

  • Direct secure messaging: michael.slack@phmg.eclinicaldirectplus.com

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1491264000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1708387200000",
    "number": "1679006076",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5111 N TRAVIS ST APT 221",
            "city": "SHERMAN",
            "state": "TX",
            "postal_code": "750924073"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4815 CLEVELAND BLVD",
            "city": "CALDWELL",
            "state": "ID",
            "postal_code": "836056501",
            "telephone_number": "208-455-3545",
            "fax_number": "208-454-9690"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5016 N US HWY 75",
            "address_purpose": "LOCATION",
            "city": "Denison",
            "state": "TX",
            "postal_code": "75020",
            "country_code": "US",
            "telephone_number": "903-416-4000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SLACK",
        "first_name": "MICHAEL",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-04-04",
        "last_updated": "2024-02-20",
        "certification_date": "2024-02-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "O-1447",
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "S3590",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Caldwell, ID

Sources for this page

Verify at the official NPI Registry.