Provider Demographics
NPI:1639860786
Name:BLACK, STEVEN D (QIDP)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:BLACK
Suffix:
Gender:M
Credentials:QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6639 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4161
Mailing Address - Country:US
Mailing Address - Phone:312-730-6710
Mailing Address - Fax:
Practice Address - Street 1:6639 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-4161
Practice Address - Country:US
Practice Address - Phone:312-730-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator