Healthcare Provider Details

I. General information

NPI: 1740509355
Provider Name (Legal Business Name): BRANDON D BLACK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 PLAIN DRIVE C/O MA ANESTHESIA CORP.
STOUGHTON MA
02072
US

IV. Provider business mailing address

PO BOX 372 MASSACHUSETTS ANESTHESIA CORP.
STOUGHTON MA
02072
US

V. Phone/Fax

Practice location:
  • Phone: 617-523-7900
  • Fax:
Mailing address:
  • Phone: 646-415-3838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2263659
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: