Healthcare Provider Details

I. General information

NPI: 1730826314
Provider Name (Legal Business Name): PHILIP BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 STATE ST
NEW ALBANY IN
47150-4990
US

IV. Provider business mailing address

1850 STATE ST
NEW ALBANY IN
47150-4990
US

V. Phone/Fax

Practice location:
  • Phone: 469-864-7376
  • Fax:
Mailing address:
  • Phone: 469-864-7376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberBP10079484
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: