1174609754 NPI number — TINA M BLACK DO

Table of content: TINA M BLACK DO (NPI 1174609754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174609754 NPI number — TINA M BLACK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
TINA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1174609754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 COLUMBIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44145-1493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-899-0900
Provider Business Mailing Address Fax Number:
440-899-0976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 COLUMBIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-1493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-899-0900
Provider Business Practice Location Address Fax Number:
440-899-0976
Provider Enumeration Date:
10/27/2006

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: 207Q00000X , with the licence number:  34005618 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0936116 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 740121 . This is a "BCHP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00338796 . This is a "CARERR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000380935 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 378646 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341542312098 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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