MEDICARE: MS. IRA-ETTA MARIE BLACK RN

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	163WC0400X	Case Management Registered Nurse	RN237736	OH

Other Identifiers

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

General Provider Information

NPI Number	:	1669621256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IRA-ETTA MARIE BLACK RN

Provider Business Mailing Address
First Line	:	2200 E 106TH ST
Second Line	:	APT #4
City	:	CLEVELAND
State	:	OH
Zip	:	44106-4258
Country	:	US
Telephone Number	:	216-229-8882
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 E 106TH ST
Second Line	:	APT #4
City	:	CLEVELAND
State	:	OH
Zip	:	44106-4258
Country	:	US
Telephone Number	:	216-229-8882
Fax Number	:

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

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	09/18/2008

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