Provider Demographics
NPI:1518506476
Name:BLACK, HUGH EDWARD JR
Entity Type:Individual
Prefix:
First Name:HUGH
Middle Name:EDWARD
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 E 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-2898
Mailing Address - Country:US
Mailing Address - Phone:614-207-8677
Mailing Address - Fax:
Practice Address - Street 1:16 W LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2815
Practice Address - Country:US
Practice Address - Phone:740-695-9344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10307655200Medicaid