Provider Demographics
NPI:1497724645
Name:BLACK, ANTHONY SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:SHANE
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6853
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-6853
Mailing Address - Country:US
Mailing Address - Phone:334-673-1488
Mailing Address - Fax:334-673-8798
Practice Address - Street 1:1491 HARTFORD HWY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3349
Practice Address - Country:US
Practice Address - Phone:334-673-1488
Practice Address - Fax:334-673-8798
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1638111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1497724645OtherNPI
AL350045914OtherRAILROAD MEDICARE PALMETTO
AL51078506OtherBLUE CROSS BLUE SHIELD