Provider Demographics
NPI:1164594735
Name:BLACK, ELLEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1367
Mailing Address - Country:US
Mailing Address - Phone:201-858-0800
Mailing Address - Fax:201-858-3367
Practice Address - Street 1:273 AVENUE A
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-1367
Practice Address - Country:US
Practice Address - Phone:201-858-0800
Practice Address - Fax:201-858-3367
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA043128207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC53003Medicare UPIN
NJ078595Medicare ID - Type Unspecified