Provider Demographics
NPI:1326239856
Name:J. LARRY BLACK MD PHD PLLC
Entity Type:Organization
Organization Name:J. LARRY BLACK MD PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-562-6026
Mailing Address - Street 1:4364 HWY 51 SOUTH
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2534
Mailing Address - Country:US
Mailing Address - Phone:662-562-6026
Mailing Address - Fax:662-562-8037
Practice Address - Street 1:4364 HWY 51 SOUTH
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2534
Practice Address - Country:US
Practice Address - Phone:662-562-6026
Practice Address - Fax:662-562-8037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMD0000008543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015649Medicaid
MSC02835Medicare PIN
MSB30160Medicare UPIN