Healthcare Provider Details

I. General information

NPI: 1699963793
Provider Name (Legal Business Name): JAMES BLACK JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106
US

IV. Provider business mailing address

3605 WARRENSVILLE CENTER ROAD 1ST FLOOR
SHAKER HTS OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-1000
  • Fax:
Mailing address:
  • Phone: 216-286-6260
  • Fax: 216-286-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number35090617
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35090617
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: