Provider Demographics
NPI:1497383400
Name:BLACK, ALYSSA GAIL (DO)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:GAIL
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1194
Mailing Address - Country:US
Mailing Address - Phone:606-780-5330
Mailing Address - Fax:606-780-2362
Practice Address - Street 1:155 BRICKLAYER ST
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164-1268
Practice Address - Country:US
Practice Address - Phone:606-286-4152
Practice Address - Fax:606-286-2385
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY05595207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY05595OtherSTATE
KY7100762470Medicaid