Provider Demographics
NPI:1659318020
Name:BLACK, ANDREW JAMES (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:BLACK
Suffix:
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 1:2215 BURDETT AVE.
Mailing Address - Street 2:HMP OF SAMARITAN
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2466
Mailing Address - Country:US
Mailing Address - Phone:518-270-3094
Mailing Address - Fax:518-270-3095
Practice Address - Street 1:2215 BURDETT AVE.
Practice Address - Street 2:HMP OF SAMARITAN
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2466
Practice Address - Country:US
Practice Address - Phone:518-270-3094
Practice Address - Fax:518-270-3095
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108517207RA0000X
NY244711208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-108517Medicaid
IL036-108517Medicaid