Provider Demographics
NPI:1700860970
Name:BLACK, GLENN RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:RAYMOND
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 1:586 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-3424
Mailing Address - Country:US
Mailing Address - Phone:330-645-6809
Mailing Address - Fax:
Practice Address - Street 1:103 5TH ST SE
Practice Address - Street 2:STE S
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-4256
Practice Address - Country:US
Practice Address - Phone:330-753-5863
Practice Address - Fax:330-753-9838
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.036808207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000191152OtherANTHEM BC/BS
OH341397094026OtherCARESOURCE
OH791063783OtherRAILROAD MEDICARE
OH0429549Medicaid
OH1786246OtherCIGNA
OH4205812OtherAETNA
OH1263551OtherUNITED MINE WORKERS
OH0400075OtherUNITED HEALTHCARE
OH729783OtherBUCKEYE COMM HEALTH PLAN
OH59634OtherQUALCHOICE
OH107535OtherKAISER
OH107535OtherKAISER
OHBL0452542Medicare ID - Type Unspecified