=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386096840
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELSPETH BLACK-CARPENTER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2016
-----------------------------------------------------
Last Update Date | 07/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4059 JANDY BLVD # 103
-----------------------------------------------------
City | NAZARETH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18064-8819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-503-6450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4059 JANDY BLVD # 103
-----------------------------------------------------
City | NAZARETH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18064-8819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-503-6450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD467840
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------