Provider Demographics
NPI:1689626913
Name:BLACK, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
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 1:123 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1216
Mailing Address - Country:US
Mailing Address - Phone:508-363-6126
Mailing Address - Fax:508-363-9266
Practice Address - Street 1:123 SUMMER STREET
Practice Address - Street 2:SUITE 380 N
Practice Address - City:WORCESTOR
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-363-6126
Practice Address - Fax:508-363-9266
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA42763207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7763607OtherUS HEALTHCARE
042472266OtherONE HEALTH PLAN
042472266OtherPRIVATE HEALTHCARE SYSTEM
26773OtherHEALTHY START
B18224OtherBLUE CARE ELECT
042472266OtherHEALTHCARE VALUE MGMT
2071908OtherMEDICAID WELFARE
26773OtherCHILDRENS MED SEC PLAN
7763607OtherAETNA
9900140OtherFALLON COMM HEALTH PLAN
202138OtherCIGNA HEALTH PLAN
MA2071908Medicaid
783998OtherMVP HEALTH CARE
AA2834OtherHARVARD PILGRAM HLTH CARE
3100051OtherEVERCARE
B18224OtherBLUE SHIELD INDEMNITY
B18224OtherBLUE SHIELD HMO BLUE
783998OtherMVP HEALTH CARE
B87078Medicare UPIN
B18224Medicare ID - Type UnspecifiedB