Provider Demographics
NPI:1710184908
Name:BLACK, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EAST PENN SQUARE
Mailing Address - Street 2:THE WANAMAKER BUILDING, 9TH FLOOR, N.
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9300
Mailing Address - Fax:
Practice Address - Street 1:34TH STREET & CIVIC CENTER BLVD
Practice Address - Street 2:SUITE 9329
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4399
Practice Address - Country:US
Practice Address - Phone:215-590-1858
Practice Address - Fax:215-590-1415
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD443506207LP3000X
PAMT191494208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA254874EJLOtherMEDICARE PTAN
PA1027597410001Medicaid