Provider Demographics
NPI:1609883313
Name:BLACK, ROSS R II (MD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:R
Last Name:BLACK
Suffix:II
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:265 PORTAGE TRAIL EXT W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-3613
Mailing Address - Country:US
Mailing Address - Phone:330-928-3111
Mailing Address - Fax:330-928-2843
Practice Address - Street 1:265 PORTAGE TRAIL EXT W
Practice Address - Street 2:SUITE 200
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-3613
Practice Address - Country:US
Practice Address - Phone:330-928-3111
Practice Address - Fax:330-928-2843
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35036057B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0276295Medicaid
D31300Medicare UPIN
OH0276295Medicaid