Healthcare Provider Details

I. General information

NPI: 1093752545
Provider Name (Legal Business Name): PAMELA O BLACK MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 COMMONS AVE NE
ALBUQUERQUE NM
87109-5831
US

IV. Provider business mailing address

PO BOX 25206
ALBUQUERQUE NM
87125-0206
US

V. Phone/Fax

Practice location:
  • Phone: 505-343-1711
  • Fax: 505-343-1862
Mailing address:
  • Phone: 505-343-1711
  • Fax: 505-343-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY JACOBSON
Title or Position: CEO
Credential:
Phone: 505-343-1711