MEDICARE: DR. EVAN H 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
1	207WX0200X	Ophthalmic Plastic and Reconstructive Surgery Physician	4301071533	MI

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	:	1932185089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVAN H BLACK MD

Provider Business Mailing Address
First Line	:	1560 E MAPLE RD
Second Line	:	SUITE 400-CREDENTIALING
City	:	TROY
State	:	MI
Zip	:	48083-1138
Country	:	US
Telephone Number	:	313-577-8900
Fax Number	:	313-577-0700

Provider Business Practice Location Address
First Line	:	4717 ST. ANTOINE
Second Line	:	KRESGE EYE INSTITUTE
City	:	DETROIT
State	:	MI
Zip	:	48201-1423
Country	:	US
Telephone Number	:	313-577-8900
Fax Number	:	313-577-0700

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	06/05/2025

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Directions to “ DR. EVAN H BLACK MD” Practice Location

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