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General NPI Number Information
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NPI Number | 1700860970
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Entity Type | Individual
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Provider Name | GLENN RAYMOND BLACK M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/01/2005
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Last Update Date | 04/02/2024
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Provider Practice Location Address
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Address Line | 103 5TH ST SE STE S
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City | BARBERTON
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State | OH
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Zip | 44203-4256
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Country | US
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Telephone | 330-753-5863
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Fax | 330-753-9838
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Provider Business Mailing Address
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Address Line | 586 MARINA DR
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City | AKRON
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State | OH
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Zip | 44319-3424
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Country | US
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Telephone | 330-645-6809
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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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 35.036808
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License Number State | OH
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