Provider Demographics
NPI:1417918053
Name:BLACK, TAMMIE ANN (DPM)
Entity Type:Individual
Prefix:DR
First Name:TAMMIE
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10417
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01041-2017
Mailing Address - Country:US
Mailing Address - Phone:413-540-0150
Mailing Address - Fax:413-540-0159
Practice Address - Street 1:81 WILLIMANSETT ST
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-3000
Practice Address - Country:US
Practice Address - Phone:413-536-0912
Practice Address - Fax:413-538-6760
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2073213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY75031Medicare PIN
MAU64998Medicare UPIN