MEDICARE: DR. STEPHANIE R BLACK M.D.

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	207R00000X	Internal Medicine Physician	036-097246	IL
2	207RI0200X	Infectious Disease Physician	036097246	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	440003692	OTHER	IL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316908791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHANIE R BLACK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 239D
Second Line	:
City	:	PARK RIDGE
State	:	IL
Zip	:	60068-8018
Country	:	US
Telephone Number	:	847-759-1560
Fax Number	:	847-803-1006

Provider Business Practice Location Address
First Line	:	600 S PAULINA ST
Second Line	:	SUITE 143
City	:	CHICAGO
State	:	IL
Zip	:	60612-3806
Country	:	US
Telephone Number	:	312-942-2061
Fax Number	:	312-942-2184

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

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	04/21/2021

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Directions to “ DR. STEPHANIE R BLACK M.D.” Practice Location

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