Provider Demographics
NPI:1639295272
Name:BLACK, AUDRIA KAYE (MD)
Entity Type:Individual
Prefix:MRS
First Name:AUDRIA
Middle Name:KAYE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 38175
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183
Mailing Address - Country:US
Mailing Address - Phone:901-755-6280
Mailing Address - Fax:901-755-7897
Practice Address - Street 1:8000 CENTERVIEW PARKWAY
Practice Address - Street 2:STE 104
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018
Practice Address - Country:US
Practice Address - Phone:901-755-6280
Practice Address - Fax:901-755-7897
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN366272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN36627OtherLICENSE
TNBB7921972OtherDEA
H68460Medicare UPIN