Physician Compare National (NPI:1508185760)

HEALTHCARE PROVIDER: LEVI COLTER BLACK CRNA

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1508185760
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	8325179534
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20190816002800
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	BLACK
	Individual professional last name
Provider First Name	LEVI
	Individual professional first name
Provider Middle Name	COLTER
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	2014
	Individual professional's medical school graduation year
Primary Specialty	CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	MAIN STREET ANESTHESIA OF NEW MEXICO, LLC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	3476807538
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	77
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	10501 GOLF COURSE RD NW
	Group Practice or individual's line 1 address
Line 2 Street Address	LOVELACE WESTSIDE HOSPITAL
	Group Practice or individual's line 2 address
City	ALBUQUERQUE
	Group Practice or individual's city
State	NM
	Group Practice or individual's state
Zip Code	871145019
	Group Practice or individual's zip code (9 digits when available)
Phone Number	5057272000
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	320086
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	LOVELACE REGIONAL HOSPITAL - ROSWELL
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y