Healthcare Provider Details

I. General information

NPI: 1831198084
Provider Name (Legal Business Name): HAROLD MICAGAH BLACK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MIKE BLACK CRNA

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JOSEPH SIEWICK DR
FAIRFAX VA
22033-1709
US

IV. Provider business mailing address

PO BOX 37090
BALTIMORE MD
21297-3090
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-3129
  • Fax: 703-295-9369
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-295-9369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024070513
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: