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General NPI Number Information
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NPI Number | 1114193919
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Entity Type | Organization
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Legal Business Name | ALAN S BLACK MD PC
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Dates
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Enumeration Date | 05/02/2008
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Last Update Date | 05/02/2008
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Provider Practice Location Address
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Address Line | 2907 LAKE FOREST DR
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City | AUGUSTA
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State | GA
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Zip | 30909-3025
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Country | US
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Telephone | 706-667-0453
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Fax |
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Provider Business Mailing Address
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Address Line | 2907 LAKE FOREST DR
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City | AUGUSTA
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State | GA
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Zip | 30909-3025
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Country | US
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Telephone | 706-667-0453
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ALAN SCOTT BLACK
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Credential | MD
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Telephone | 706-667-0453
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 34542
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License Number State | GA
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