Provider Demographics
NPI:1376767483
Name:BLACK, MELISSA PHILLIPS (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:PHILLIPS
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1365 CLIFTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-728-6363
Mailing Address - Fax:404-728-6298
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-728-6363
Practice Address - Fax:404-728-6298
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056266207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine