Provider Demographics
NPI:1790988087
Name:BLACK, CHARLES HENRY IV (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HENRY
Last Name:BLACK
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:HENRY
Other - Last Name:BLACK
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-649-5990
Mailing Address - Fax:601-425-7510
Practice Address - Street 1:1002 JEFFERSON ST.
Practice Address - Street 2:SUITE 350
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4306
Practice Address - Country:US
Practice Address - Phone:601-649-5990
Practice Address - Fax:601-425-7510
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016776207X00000X
MS23113207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08107236Medicaid