1134110109 NPI number — DR. IAN H BLACK MD

Table of content: DR. IAN H BLACK MD (NPI 1134110109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134110109 NPI number — DR. IAN H BLACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
IAN
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134110109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 16TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREELEY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80631-5154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLCHESTER AVE
Provider Second Line Business Practice Location Address:
FLETCHER ALLEN HEALTH CARE DEPARTMENT OF ANESTHESIOLOGY
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-847-2415
Provider Business Practice Location Address Fax Number:
802-847-5324
Provider Enumeration Date:
10/31/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  01053867A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LC0200X , with the licence number: 042-0011556 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 042-0011556 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: DR.0065589 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207L00000X , with the licence number: 042-0011556 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)