Provider Demographics
NPI:1609800598
Name:BLACK, WILLIAM L JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-966-5527
Mailing Address - Fax:765-966-5528
Practice Address - Street 1:1485 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1919
Practice Address - Country:US
Practice Address - Phone:765-966-5527
Practice Address - Fax:765-966-5527
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042757A207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3160510Medicaid
000000681708OtherANTHEM BCBS (RPA)
IN201003480Medicaid
000000681708OtherANTHEM BCBS (RPA)
IN902290KMedicare PIN
ING55670Medicare UPIN
OH2075098Medicaid
IN200146850Medicaid
IN00000082679OtherANTHEM
INP00682287OtherMEDICARE RAIL ROAD
IN903830HHMedicare ID - Type UnspecifiedREID HOSPITAL - EKG
INDEA#OtherBB5105778
IN110163349Medicare PIN