Provider Demographics
NPI:1669495255
Name:BLACK, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:146 N HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 530
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4894
Mailing Address - Country:US
Mailing Address - Phone:803-796-7270
Mailing Address - Fax:803-796-0106
Practice Address - Street 1:146 N HOSPITAL DRIVE
Practice Address - Street 2:SUITE 530
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4894
Practice Address - Country:US
Practice Address - Phone:803-796-7270
Practice Address - Fax:803-796-0106
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC8343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC083439Medicaid
C60599Medicare PIN