Healthcare Provider Details

I. General information

NPI: 1356729859
Provider Name (Legal Business Name): ELIZABETH BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

320 E NORTH AVE
PITTSBURGH PA
15212-4756
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 412-359-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.146792
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: