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General NPI Number Information
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NPI Number | 1326239856
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Entity Type | Organization
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Legal Business Name | J. LARRY BLACK MD PHD PLLC
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Dates
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Enumeration Date | 08/08/2007
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Last Update Date | 12/17/2007
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Provider Practice Location Address
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Address Line | 4364 HWY 51 SOUTH
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City | SENATOBIA
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State | MS
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Zip | 38668-2534
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Country | US
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Telephone | 662-562-6026
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Fax | 662-562-8037
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Provider Business Mailing Address
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Address Line | 4364 HWY 51 SOUTH
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City | SENATOBIA
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State | MS
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Zip | 38668-2534
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Country | US
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Telephone | 662-562-6026
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Fax | 662-562-8037
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Authorized Official
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Title or Position | PRESIDENT
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Name | J LARRY BLACK
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Credential | MD
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Telephone | 662-562-6026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD0000008543
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License Number State | MS
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