Healthcare Provider Details

I. General information

NPI: 1285256909
Provider Name (Legal Business Name): KEVIN ZACHARY BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 W EVERGREEN AVE STE 200
EFFINGHAM IL
62401-1638
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-3400
  • Fax: 217-342-6417
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036181434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: