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General NPI Number Information
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NPI Number | 1447264494
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Entity Type | Individual
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Provider Name | MARY ELIZABETH BLACK
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Gender | Female
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 06/11/2015
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Provider Practice Location Address
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Address Line | 489 STATE ST
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City | BANGOR
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State | ME
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Zip | 04401-6616
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Country | US
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Telephone | 207-973-8670
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Fax |
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Provider Business Mailing Address
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Address Line | 186 NORTHPORT AVE
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City | BELFAST
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State | ME
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Zip | 04915-6073
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Country | US
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Telephone | 207-338-2010
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080N0001X
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Taxonomy Name | Neonatal-Perinatal Medicine Physician
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License Number | 12141
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License Number State | ME
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