Provider Demographics
NPI:1659992741
Name:BLACK, KRISTIAN MARQUIS (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:MARQUIS
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 1:1500 E MEDICAL CENTER DRIVE
Mailing Address - Street 2:3875 TAUBMAN CENTER, SPC 5330
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5330
Mailing Address - Country:US
Mailing Address - Phone:734-615-0563
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DRIVE
Practice Address - Street 2:TAUBMAN CENTER, 2ND FLOOR, RECEPTION C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5330
Practice Address - Country:US
Practice Address - Phone:734-936-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351045854390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program