Provider Demographics
NPI:1063478675
Name:BLACK, WILLIAM S (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1006 FORD AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4677
Practice Address - Country:US
Practice Address - Phone:270-688-2110
Practice Address - Fax:270-688-2111
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY28129207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64281298Medicaid
KY64281298Medicaid
KY0631245Medicare ID - Type Unspecified