Healthcare Provider Details

I. General information

NPI: 1801853593
Provider Name (Legal Business Name): BARRY G. BLACK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 14TH AVE SE
DECATUR AL
35601-3361
US

IV. Provider business mailing address

1900 FLINT RD SE
DECATUR AL
35601-6031
US

V. Phone/Fax

Practice location:
  • Phone: 256-560-2890
  • Fax: 256-350-2609
Mailing address:
  • Phone: 256-353-0626
  • Fax: 256-350-2609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-066229
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: