Provider Demographics
NPI:1437255239
Name:BLACK, BRIAN HOUSTON (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:HOUSTON
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 INDIANAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-2408
Mailing Address - Country:US
Mailing Address - Phone:765-653-8453
Mailing Address - Fax:
Practice Address - Street 1:1542 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2297
Practice Address - Country:US
Practice Address - Phone:765-301-7617
Practice Address - Fax:317-301-7621
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002904A207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200521550Medicaid
INP00332798OtherRAILROAD MEDICARE
IN1437255239OtherNPI
IN681070EMedicare PIN
IN200521550Medicaid