MEDICARE: DR. TRACY M 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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	9400724	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	2337913	OTHER	NC	MEDICARE LEGACY ID

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
2	P00163549	OTHER	NC	RAILROAD
4	4646370	OTHER	NC	AETNA
5	12086	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1700853660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY M BLACK M.D.

Provider Business Mailing Address
First Line	:	5213 S ALSTON AVE
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-4430
Country	:	US
Telephone Number	:	919-620-4467
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 N ROXBORO ST
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-1826
Country	:	US
Telephone Number	:	919-471-1518
Fax Number	:

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	01/30/2013

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