Provider Demographics
NPI:1003815267
Name:BLACK, GLORIA GILBERT (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:GILBERT
Last Name:BLACK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37090
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3090
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-295-9369
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-295-9360
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024076529207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003815267Medicaid
VA296621OtherAMERIGROUP
VAK142-0002OtherCAREFIRST
VA139180OtherANTHEM
VA296621OtherAMERIGROUP
VA001119A50Medicare ID - Type UnspecifiedPROVIDER ID
VAP00247229Medicare ID - Type UnspecifiedRAILROAD
VA139180OtherANTHEM