Healthcare Provider Details

I. General information

NPI: 1790988087
Provider Name (Legal Business Name): CHARLES HENRY BLACK IV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHARLES HENRY BLACK IV D.O.

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MEDICAL CENTER DR
WILMINGTON NC
28401-7307
US

IV. Provider business mailing address

1202 MEDICAL CENTER DR
WILMINGTON NC
28401-7307
US

V. Phone/Fax

Practice location:
  • Phone: 910-341-3498
  • Fax: 910-762-1698
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number23113
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20A24530
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101016776
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2026-01868
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: