Provider Demographics
NPI:1235158833
Name:BLACK, JAMES E (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
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 1:811 HOLLY DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-4318
Mailing Address - Country:US
Mailing Address - Phone:904-234-5425
Mailing Address - Fax:229-432-9550
Practice Address - Street 1:5505 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:904-234-5425
Practice Address - Fax:229-432-9550
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057777207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA993056118BMedicaid
GA359337OtherWELLCARE
GA52991520-002OtherBCBS
GA993056118AMedicaid
GA52991520-001OtherBCBS
GA993056118AMedicaid
GAI56078Medicare UPIN