Basic Information
Provider Information
NPI: 1003015728
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLACK
FirstName: ROBERT
MiddleName: E
NamePrefix: DR.
NameSuffix: III
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 551420
Address2:  
City: FORT LAUDERDALE
State: FL
PostalCode: 333551420
CountryCode: US
TelephoneNumber: 8002433839
FaxNumber: 9548392569
Practice Location
Address1: 1000 MEDICAL CENTER BLVD
Address2:  
City: LAWRENCEVILLE
State: GA
PostalCode: 300460000
CountryCode: US
TelephoneNumber: 7702773056
FaxNumber: 8552045244
Other Information
ProviderEnumerationDate: 07/12/2007
LastUpdateDate: 04/02/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000X067920GAY Allopathic & Osteopathic PhysiciansAnesthesiology 
207L00000X67920GAN Allopathic & Osteopathic PhysiciansAnesthesiology 

ID Information
IDTypeStateIssuerDescription
003126898A05GA MEDICAID


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