Provider Demographics
NPI:1073552105
Name:BLACK, ANDREW S (DPM, PA)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:S
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPM, PA
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Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2099
Practice Address - Street 1:100 JOHN ROEMMELT DR STE 102
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8302
Practice Address - Country:US
Practice Address - Phone:607-795-1666
Practice Address - Fax:607-796-0839
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY006707213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04308852Medicaid
PA103755030Medicaid
NJ1531603Medicaid
NJ1531603Medicaid