Healthcare Provider Details

I. General information

NPI: 1497719603
Provider Name (Legal Business Name): KEVIN P BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HOPE DR STE 2400
HERSHEY PA
17033
US

IV. Provider business mailing address

PO BOX 858 MC A410
HERSHEY PA
17033-0858
US

V. Phone/Fax

Practice location:
  • Phone: 717-531-5638
  • Fax: 717-531-0983
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD049633L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD049633L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: