Healthcare Provider Details

I. General information

NPI: 1437656659
Provider Name (Legal Business Name): MARA BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-1400
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD94025
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number042.0040390
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: