Healthcare Provider Details

I. General information

NPI: 1336723840
Provider Name (Legal Business Name): CARL BLACK JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 E HUNTING PARK AVE
PHILADELPHIA PA
19124-4928
US

IV. Provider business mailing address

1216 E HUNTING PARK AVE
PHILADELPHIA PA
19124-4928
US

V. Phone/Fax

Practice location:
  • Phone: 215-533-1333
  • Fax: 215-744-4324
Mailing address:
  • Phone: 215-533-1333
  • Fax: 215-744-4324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA005627
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: