MEDICARE: CURTIS JAY BLACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME 17786	FL

General Provider Information

NPI Number	:	1265524391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CURTIS JAY BLACK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2699
Second Line	:	ATTN: SHMG/HPE
City	:	PENSACOLA
State	:	FL
Zip	:	32513-2699
Country	:	US
Telephone Number	:	850-568-1053
Fax Number	:	850-568-1053

Provider Business Practice Location Address
First Line	:	807 HIGHWAY 22
Second Line	:
City	:	WEWAHITCHKA
State	:	FL
Zip	:	32465-3237
Country	:	US
Telephone Number	:	850-568-1053
Fax Number	:	850-568-1053

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	10/29/2015

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