Healthcare Provider Details

I. General information

NPI: 1710970330
Provider Name (Legal Business Name): FRED BLACK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 NW TROOST ST SUITE 103
ROSEBURG OR
97471-6071
US

IV. Provider business mailing address

2282 NW TROOST ST SUITE 103
ROSEBURG OR
97471-6071
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-0497
  • Fax: 541-957-2663
Mailing address:
  • Phone: 541-672-0497
  • Fax: 541-957-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD10476
License Number StateOR

VIII. Authorized Official

Name: FREDERICK J BLACK
Title or Position: PRESIDENT
Credential: MD
Phone: 541-672-0497