Healthcare Provider Details

I. General information

NPI: 1194188094
Provider Name (Legal Business Name): SAMUEL BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W BELVEDERE AVE
BALTIMORE MD
21215-5216
US

IV. Provider business mailing address

2401 W BELVEDERE AVE
BALTIMORE MD
21215-5216
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-0594
  • Fax: 410-601-0939
Mailing address:
  • Phone: 410-601-0594
  • Fax: 410-601-0939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0087167
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD87167
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: