Provider Demographics
NPI:1871761601
Name:JAMES D BLACK
Entity type:Organization
Organization Name:JAMES D BLACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-882-7480
Mailing Address - Street 1:18010 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-6235
Mailing Address - Country:US
Mailing Address - Phone:313-882-7480
Mailing Address - Fax:313-882-7525
Practice Address - Street 1:18010 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-6235
Practice Address - Country:US
Practice Address - Phone:313-882-7480
Practice Address - Fax:248-652-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
MIJB001105332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI485635035OtherBCBSM
MI5635035OtherPTAN
MI1626185Medicaid
MI0731430001Medicare NSC
MI5635035Medicare PIN
MI5635035OtherPTAN