Healthcare Provider Details

I. General information

NPI: 1972739001
Provider Name (Legal Business Name): MICHELLE T BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 NE MEDICAL CENTER DR
BEND OR
97701-6061
US

IV. Provider business mailing address

1460 NE MEDICAL CENTER DR
BEND OR
97701-6061
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-6633
  • Fax: 541-383-4577
Mailing address:
  • Phone: 541-382-6633
  • Fax: 541-383-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number113466
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD18981
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number57945
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD226250
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-39604
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number29776
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: