Basic Information
Provider Information | |||||||||
NPI: | 1699963793 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACK | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3605 WARRENSVILLE CENTER ROAD | ||||||||
Address2: | 1ST FLOOR | ||||||||
City: | SHAKER HTS | ||||||||
State: | OH | ||||||||
PostalCode: | 44122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162866260 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Practice Location | |||||||||
Address1: | 11100 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 44106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168441000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2007 | ||||||||
LastUpdateDate: | 12/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146N00000X | 35090617 | OH | N |   | Emergency Medical Service Providers | Emergency Medical Technician, Basic |   | 207P00000X | 35090617 | OH | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000226039 | 01 | OH | UNISON | OTHER | 421771 | 01 | OH | WELLCARE MEDICAID | OTHER | 751474 | 01 | OH | BUCKEYE MEDICAID | OTHER | P00432283 | 01 | OH | RAILROAD MEDICARE | OTHER | 2775644 | 05 | OH |   | MEDICAID | 000000538614 | 01 | OH | ANTHEM | OTHER | 9219089 | 01 | OH | AETNA | OTHER |