Provider Demographics
NPI:1093817082
Name:BLACK, HARVEY E (MD)
Entity Type:Individual
Prefix:MR
First Name:HARVEY
Middle Name:E
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5813 EAST SEYMOUR ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039
Mailing Address - Country:US
Mailing Address - Phone:315-699-2789
Mailing Address - Fax:315-699-6251
Practice Address - Street 1:5813 EAST SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039
Practice Address - Country:US
Practice Address - Phone:315-699-2789
Practice Address - Fax:315-699-6251
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
508560Medicare ID - Type Unspecified
C59402Medicare UPIN