Provider Demographics
NPI:1578546438
Name:BLACK, STEVEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8244
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-8244
Mailing Address - Country:US
Mailing Address - Phone:575-624-2095
Mailing Address - Fax:575-208-0780
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:575-624-2095
Practice Address - Fax:575-208-0780
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0547207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66933862Medicaid
NM66933862Medicaid
NM66933862Medicaid
NM282568YLCWMedicare PIN
NCI44776Medicare UPIN
NC5901153Medicaid