1700860970 NPI number — DR. GLENN RAYMOND BLACK M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700860970 NPI number — DR. GLENN RAYMOND BLACK M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BLACK

Provider First Name:

GLENN

Provider Middle Name:

RAYMOND

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1700860970

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/02/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

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 First Line Business Practice Location Address:

103 5TH ST SE

Provider Second Line Business Practice Location Address:

STE S

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:

330-753-9838

Provider Enumeration Date:

12/01/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• 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" .

• 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: 341397094026 . This is a "CARESOURCE" 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".
• Identifier: 0400075 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 729783 . This is a "BUCKEYE COMM HEALTH PLAN" 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: 0429549 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 1263551 . This is a "UNITED MINE WORKERS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 59634 . This is a "QUALCHOICE" 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".