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1124473749

NPI Code Detail

MEDICARE: CARLA MARIE BLACK MD

MEDICARE: CARLA MARIE BLACK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	01087770A	IN
2	2084P0800X	Psychiatry Physician	310168	LA
3	2084P0800X	Psychiatry Physician	01087770A	IN
4	390200000X	Student in an Organized Health Care Education/Training Program
5	2084P0804X	Child & Adolescent Psychiatry Physician	01087770A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1102529646	OTHER	IN	ANTHEM PTAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124473749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA MARIE BLACK MD

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6640 INTECH BLVD STE 195
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46278-2014
Country	:	US
Telephone Number	:	317-295-0608
Fax Number	:	317-948-0609

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	05/15/2025

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1801412895 — LISA DIANE CARRICO
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Directions to “ CARLA MARIE BLACK MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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