Basic Information
Provider Information | |||||||||
NPI: | 1275793358 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACK | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | PREVATT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PREVATT | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: | RENEE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 191 | ||||||||
Address2: | PROVIDER ENROLLMENT DEPARTMENT, | ||||||||
City: | ROCKLAND | ||||||||
State: | DE | ||||||||
PostalCode: | 197320191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026514488 | ||||||||
FaxNumber: | 3026514945 | ||||||||
Practice Location | |||||||||
Address1: | 807 CHILDRENS WAY | ||||||||
Address2: | NEMOURS CHILDRENS CLINIC, | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322078426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9046973600 | ||||||||
FaxNumber: | 9046973792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2008 | ||||||||
LastUpdateDate: | 09/16/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207YP0228X | ME115569 | FL | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
ID | Type | State | Issuer | Description | '009304000 | 05 | FL |   | MEDICAID |