Provider Demographics
NPI:1598889123
Name:BLACK, MICHELLE RAEGENE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAEGENE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:RAEGENE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5303 E EVANS AVE
Mailing Address - Street 2:SUITE #302
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-5229
Mailing Address - Country:US
Mailing Address - Phone:303-777-3788
Mailing Address - Fax:303-940-7773
Practice Address - Street 1:1200 CHEROKEE ST
Practice Address - Street 2:UNIT #203
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-3664
Practice Address - Country:US
Practice Address - Phone:303-601-5171
Practice Address - Fax:303-223-0981
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO246ZS0400X246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50416OtherATHEM
CO5214875OtherCIGNA