1326253238 NPI number — GLENN R BLACK MD INC

Table of content: (NPI 1326253238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326253238 NPI number — GLENN R BLACK MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLENN R BLACK MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1326253238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
586 MARINA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44319-3424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-645-6809
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 5TH ST SE STE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBERTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44203-4256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-753-5863
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
330-753-5863

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  35.036808 , 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: 59634 . This is a "QUALCHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0429549 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 274462003005 . This is a "MEDICAL MUTUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 107535 . This is a "KAISER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1786246 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 274462003-00 . This is a "BWC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1263551 . This is a "UMW" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 295174 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 729783 . This is a "BCHP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 791063783 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0400075 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 354693 . This is a "ADVANTRA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4205812 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: Q014575 . This is a "HOMETOWN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000191152 . This is a "ANTHEM BC BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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