Healthcare Provider Details

I. General information

NPI: 1710564539
Provider Name (Legal Business Name): JONATHAN REID BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 19TH ST S
BIRMINGHAM AL
35233-1900
US

IV. Provider business mailing address

PO BOX 55310
BIRMINGHAM AL
35255-5310
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-4011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number335155
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number45256
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: