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NPI Code Detail

MEDICARE: DR. MARY E BLACK MD

MEDICARE: DR. MARY E 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
1207Q00000XFamily Medicine Physician131116FL
2207Q00000XFamily Medicine PhysicianTEMPORARYTX

General Provider Information

NPI Number : 1417375510
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARY E BLACK MD
Provider Business Mailing Address
First Line : 825 E RUNDBERG LN STE B1
Second Line :
City : AUSTIN
State : TX
Zip : 78753-4860
Country : US
Telephone Number : 512-978-9600
Fax Number : 512-901-9771
Provider Business Practice Location Address
First Line : 825 E RUNDBERG LN STE B1
Second Line :
City : AUSTIN
State : TX
Zip : 78753-4860
Country : US
Telephone Number : 512-978-9600
Fax Number : 512-901-9771
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/04/2014
Last Update Date : 10/08/2018

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Directions to “ DR. MARY E BLACK MD” Practice Location

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