Healthcare Provider Details

I. General information

NPI: 1932687407
Provider Name (Legal Business Name): MR. THOMAS HARRISON BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E MCNICHOLS RD
DETROIT MI
48203-2857
US

IV. Provider business mailing address

8290 E 10 MILE RD # A-15
CENTER LINE MI
48015-1412
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-3113
  • Fax:
Mailing address:
  • Phone: 586-823-1465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: