Healthcare Provider Details

I. General information

NPI: 1881681732
Provider Name (Legal Business Name): EARL BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46591 ROMEO PLANK RD
MACOMB MI
48044-5742
US

IV. Provider business mailing address

43800 GARFIELD RD
CLINTON TWP MI
48038-1136
US

V. Phone/Fax

Practice location:
  • Phone: 586-443-4950
  • Fax: 586-443-4980
Mailing address:
  • Phone: 800-848-0202
  • Fax: 586-226-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301023839
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: