1346260247 NPI number — DR. EVAN GEORGE BLACK M.D.

Table of content: DR. EVAN GEORGE BLACK M.D. (NPI 1346260247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346260247 NPI number — DR. EVAN GEORGE BLACK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
EVAN
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1346260247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5323 WOODROW ST
Provider Second Line Business Mailing Address:
#201
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-5841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-261-4711
Provider Business Mailing Address Fax Number:
801-261-4769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5323 WOODROW ST
Provider Second Line Business Practice Location Address:
#201
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-5841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-261-4711
Provider Business Practice Location Address Fax Number:
801-261-4769
Provider Enumeration Date:
07/20/2006

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: 2084N0400X , with the licence number:  MD476184 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 187597-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 21619 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 99622 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 89191 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: MD205738 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111197600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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