MEDICARE: MARY 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	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	81-4065881	OTHER	MI	FEIN

General Provider Information

NPI Number	:	1750823456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BLACK

Provider Business Mailing Address
First Line	:	1427 OAKLAND ST
Second Line	:
City	:	SAINT CLAIR
State	:	MI
Zip	:	48079-5122
Country	:	US
Telephone Number	:	810-650-5902
Fax Number	:	800-305-6764

Provider Business Practice Location Address
First Line	:	1427 OAKLAND ST
Second Line	:
City	:	SAINT CLAIR
State	:	MI
Zip	:	48079-5122
Country	:	US
Telephone Number	:	810-650-5902
Fax Number	:	800-305-6764

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

Provider Enumeration Date	:	11/11/2016
Last Update Date	:	11/11/2016

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