1497061626 NPI number — EMILY R BLACK NP

Table of content: EMILY R BLACK NP (NPI 1497061626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497061626 NPI number — EMILY R BLACK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
EMILY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1497061626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 1ST ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55905-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-284-2511
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 1ST ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55905-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-284-2511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2010

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: 363L00000X , with the licence number:  R 169353-9 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 515 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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