1811569106 NPI number — EUGENIA BLACK OWNER

Table of content: MAXWELL OLIVER ROLLINS MD (NPI 1336552447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811569106 NPI number — EUGENIA BLACK OWNER

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LLC
Provider Other First Name:
COMPASSION
Provider Other Middle Name:
EXPERTS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OWNER
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1811569106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51541 BITTERSWEET RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-4987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-400-7270
Provider Business Mailing Address Fax Number:
574-222-2658

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51541 BITTERSWEET RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46530-4987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-400-7270
Provider Business Practice Location Address Fax Number:
574-222-2658
Provider Enumeration Date:
07/15/2021

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: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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