Provider Demographics
NPI:1548387756
Name:ADVANCED CARDIOLOGY OF TEXARKANA PA
Entity Type:Organization
Organization Name:ADVANCED CARDIOLOGY OF TEXARKANA PA
Other - Org Name:DOUGLAS SCOTT BLACK, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-794-8820
Mailing Address - Street 1:5502 MEDICAL PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4623
Mailing Address - Country:US
Mailing Address - Phone:903-794-8820
Mailing Address - Fax:
Practice Address - Street 1:5502 MEDICAL PARKWAY DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4623
Practice Address - Country:US
Practice Address - Phone:903-794-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0033207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00884VMedicare ID - Type Unspecified
OKDA8355Medicare PIN