MEDICARE: STEPHEN BLACK

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124444	OTHER	TX	LICENSE#

General Provider Information

NPI Number	:	1356428957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN BLACK

Provider Business Mailing Address
First Line	:	7419 BLUEFIELD DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-3011
Country	:	US
Telephone Number	:	972-702-0584
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 N ALLEN DR STE 104
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75013-2575
Country	:	US
Telephone Number	:	972-727-1931
Fax Number	:

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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Directions to “ STEPHEN BLACK ” Practice Location

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