Healthcare Provider Details

I. General information

NPI: 1124697958
Provider Name (Legal Business Name): SAMUEL JACOB BLACK MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 N BROAD ST
PHILADELPHIA PA
19140-5185
US

IV. Provider business mailing address

3401 N BROAD ST STE 810
PHILADELPHIA PA
19140-5189
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-1800
  • Fax:
Mailing address:
  • Phone: 215-707-4085
  • Fax: 215-707-5978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMT222514
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: