MEDICARE: CHARLES DEWAYNE BLACK D.O.

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	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	3023	OK

General Provider Information

NPI Number	:	1891757860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES DEWAYNE BLACK D.O.

Provider Business Mailing Address
First Line	:	4401 W MEMORIAL RD
Second Line	:	SUITE 121
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-1785
Country	:	US
Telephone Number	:	405-751-4664
Fax Number	:	405-749-4561

Provider Business Practice Location Address
First Line	:	1011 14TH AVE NW
Second Line	:	ER DEPT.
City	:	ARDMORE
State	:	OK
Zip	:	73401-1828
Country	:	US
Telephone Number	:	580-220-6415
Fax Number	:	405-749-4561

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

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	11/09/2007

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