Provider Demographics
NPI:1033495890
Name:BLACK, KEITH R (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:349 NILES CORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1976
Mailing Address - Country:US
Mailing Address - Phone:330-372-0260
Mailing Address - Fax:330-372-0261
Practice Address - Street 1:349 NILES CORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1976
Practice Address - Country:US
Practice Address - Phone:330-372-0260
Practice Address - Fax:330-372-0261
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010851207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103905Medicaid