Provider Demographics
NPI:1578524377
Name:BLACK, JOSEPH M (M D)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:BLACK
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 NW EDENBOWER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8829
Mailing Address - Country:US
Mailing Address - Phone:541-580-5328
Mailing Address - Fax:541-727-5360
Practice Address - Street 1:2550 NW EDENBOWER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8829
Practice Address - Country:US
Practice Address - Phone:541-580-5328
Practice Address - Fax:541-727-5360
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20220207RG0100X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151095Medicaid
ORR131949Medicare PIN
OR151095Medicaid