Provider Demographics
NPI:1205195138
Name:BLACK, CHRISTOPHER MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
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:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-438-9300
Mailing Address - Fax:
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-12
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016024020207RH0002X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program