Provider Demographics
NPI:1487644902
Name:BLACK, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 POST RD
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-1838
Mailing Address - Country:US
Mailing Address - Phone:401-886-4830
Mailing Address - Fax:401-886-4888
Practice Address - Street 1:65 SOCKANOSSET CROSSROADS
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6068
Practice Address - Country:US
Practice Address - Phone:401-943-1454
Practice Address - Fax:401-943-1140
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD066072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7000965Medicaid
F00734Medicare UPIN