Provider Demographics
NPI:1255863866
Name:BLACK, ELEANORE KRISTY (MD)
Entity Type:Individual
Prefix:DR
First Name:ELEANORE
Middle Name:KRISTY
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 1:38 VOLUNTEER LN APT 4E
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5463
Mailing Address - Country:US
Mailing Address - Phone:203-863-3409
Mailing Address - Fax:
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4608
Practice Address - Country:US
Practice Address - Phone:203-863-3409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-02
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT65343208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program