Provider Demographics
NPI:1669446167
Name:BLACK, MICHAEL B (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
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 1:12598 PINK MYRTLE CT
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33473-7127
Mailing Address - Country:US
Mailing Address - Phone:954-288-6500
Mailing Address - Fax:
Practice Address - Street 1:1613 HARRISON PKWY
Practice Address - Street 2:#200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2853
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:951-851-1758
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81928207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260780800Medicaid
FL58886YMedicare ID - Type Unspecified
G74168Medicare UPIN