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NPI Code Detail

MEDICARE: CARL M BLACK MD

MEDICARE: CARL M BLACK MD
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
12085R0202XDiagnostic Radiology Physician4737479-1205UT
22085N0904XNuclear Radiology Physician4737479-1205UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1870284448CB1OTHERUTEMIA
247374791204001OTHERUTBLUE CROSS
3666798OTHERUTDMBA
4107008883101OTHERUTIHC

General Provider Information

NPI Number : 1891737094
Entity Type Code : Individual
Provider Name (Legal Business Name) : CARL M BLACK MD
Provider Business Mailing Address
First Line : PO BOX 30180
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84130-0180
Country : US
Telephone Number : 801-351-4423
Fax Number :
Provider Business Practice Location Address
First Line : 1034 N 500 W
Second Line :
City : PROVO
State : UT
Zip : 84604-3380
Country : US
Telephone Number : 801-357-4423
Fax Number : 801-357-7626
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/12/2006
Last Update Date : 06/05/2026

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