Provider Demographics
NPI:1932214251
Name:BLACK, MOLLY DIANNE (MD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:DIANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-473-0637
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:875 SWIFT BLVD STE A
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3513
Practice Address - Country:US
Practice Address - Phone:509-946-1654
Practice Address - Fax:509-943-5652
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2021015522207X00000X
WAMD61559996207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123359Medicaid
NC2057101Medicare PIN
IL1291050001Medicare NSC