Healthcare Provider Details

I. General information

NPI: 1902074115
Provider Name (Legal Business Name): DR EVAN G BLACK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 WOODROW ST # 120W SUITE 201
MURRAY UT
84107-5841
US

IV. Provider business mailing address

PO BOX 95970
SOUTH JORDAN UT
84095-0970
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-4711
  • Fax: 801-261-4769
Mailing address:
  • Phone: 801-352-9500
  • Fax: 801-352-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number187597-1205
License Number StateUT

VIII. Authorized Official

Name: JENNIFER DAWSON
Title or Position: CLINIC MANAGER
Credential:
Phone: 801-408-5702