1790988087 NPI number — DR. CHARLES HENRY BLACK IV D.O.

Table of content: DR. CHARLES HENRY BLACK IV D.O. (NPI 1790988087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790988087 NPI number — DR. CHARLES HENRY BLACK IV D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
CHARLES
Provider Middle Name:
HENRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
IV
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACK
Provider Other First Name:
CHARLES
Provider Other Middle Name:
HENRY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
IV
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1790988087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39441-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-649-5990
Provider Business Mailing Address Fax Number:
601-425-7510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 JEFFERSON ST.
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39440-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-649-5990
Provider Business Practice Location Address Fax Number:
601-425-7510
Provider Enumeration Date:
06/06/2007

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: 207X00000X , with the licence number:  5101016776 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 23113 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08107236 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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