Provider Demographics
NPI:1326253238
Name:GLENN R BLACK MD INC
Entity Type:Organization
Organization Name:GLENN R BLACK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACC
Authorized Official - Phone:330-753-5863
Mailing Address - Street 1:586 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-3424
Mailing Address - Country:US
Mailing Address - Phone:330-645-6809
Mailing Address - Fax:
Practice Address - Street 1:103 5TH ST SE STE S
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-4256
Practice Address - Country:US
Practice Address - Phone:330-753-5863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.036808207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH59634OtherQUALCHOICE
OH0429549Medicaid
OH274462003005OtherMEDICAL MUTUAL
OH107535OtherKAISER
OH1786246OtherCIGNA
OH274462003-00OtherBWC
OH1263551OtherUMW
OH295174OtherFEDERAL BLACK LUNG
OH729783OtherBCHP
OH791063783OtherRAILROAD MEDICARE
OH0400075OtherUNITED HEALTHCARE
OH354693OtherADVANTRA
OH4205812OtherAETNA
OHQ014575OtherHOMETOWN
OH000000191152OtherANTHEM BC BS
OH791063783OtherRAILROAD MEDICARE
OH791063783OtherRAILROAD MEDICARE