1063478675 NPI number — WILLIAM S BLACK MD

Table of content: WILLIAM S BLACK MD (NPI 1063478675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063478675 NPI number — WILLIAM S BLACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
WILLIAM
Provider Middle Name:
S
Provider Name Prefix Text:
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:
1063478675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23229
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42304-3229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-688-1330
Provider Business Mailing Address Fax Number:
270-688-1338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 FORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42301-4677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-688-2110
Provider Business Practice Location Address Fax Number:
270-688-2111
Provider Enumeration Date:
04/22/2006

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: 207QS0010X , with the licence number:  28129 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 28129 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64281298 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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