Healthcare Provider Details

I. General information

NPI: 1649269473
Provider Name (Legal Business Name): BRIAN EDWARD BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5881
  • Fax: 305-585-3322
Mailing address:
  • Phone: 305-585-5881
  • Fax: 305-585-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number31096
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number31096
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number31096
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberME138640
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: