MEDICARE: MIKE A BLACK CEPS, NREMT

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	146N00000X	Basic Emergency Medical Technician	E1160515
2	246W00000X	Cardiology Technician	60434882	WA
3	207RC0001X	Clinical Cardiac Electrophysiology Physician	161255	DC

General Provider Information

NPI Number	:	1942716998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE A BLACK CEPS, NREMT

Provider Business Mailing Address
First Line	:	PO BOX 57768
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84157-0768
Country	:	US
Telephone Number	:	916-217-1584
Fax Number	:	866-722-1584

Provider Business Practice Location Address
First Line	:	4989 S STATE ST UNIT 57768
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84157-5032
Country	:	US
Telephone Number	:	916-217-1584
Fax Number	:	866-722-1584

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

Provider Enumeration Date	:	12/28/2017
Last Update Date	:	05/03/2019

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