MEDICARE: MR. CARL BLACK JR. PA-C

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	363AM0700X	Medical Physician Assistant	OA005627	PA

General Provider Information

NPI Number	:	1336723840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL BLACK JR. PA-C

Provider Business Mailing Address
First Line	:	1216 E HUNTING PARK AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-4928
Country	:	US
Telephone Number	:	215-533-1333
Fax Number	:	215-744-4324

Provider Business Practice Location Address
First Line	:	1216 E HUNTING PARK AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-4928
Country	:	US
Telephone Number	:	215-533-1333
Fax Number	:	215-744-4324

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

Provider Enumeration Date	:	05/11/2021
Last Update Date	:	05/11/2021

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Directions to “ MR. CARL BLACK JR. PA-C” Practice Location

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