Provider Demographics
NPI:1699036475
Name:BLACK, CARA KAY (OTR)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:KAY
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKS MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:16114-2320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0173491275N00000X, 282N00000X
PAOCO11922282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit