Provider Demographics
NPI:1669473955
Name:BLACK, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:141 LONGWATER DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061
Mailing Address - Country:US
Mailing Address - Phone:781-792-4136
Mailing Address - Fax:781-878-6750
Practice Address - Street 1:340 WOOD ROAD
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184
Practice Address - Country:US
Practice Address - Phone:781-878-5200
Practice Address - Fax:781-878-6750
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3093158Medicaid
MA110051363AMedicaid
MA3093158Medicaid