Provider Demographics
NPI:1801018122
Name:BLACK, KATHERINE ROLLINS (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ROLLINS
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 1:1130 NW 22ND AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2911
Mailing Address - Country:US
Mailing Address - Phone:503-229-7137
Mailing Address - Fax:503-241-0628
Practice Address - Street 1:1130 NW 22ND AVE STE 410
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2911
Practice Address - Country:US
Practice Address - Phone:503-229-7137
Practice Address - Fax:503-241-0628
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD156824207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500647193Medicaid
ORMD156824OtherPROVIDER STATE LICENSE
ORMD156824OtherPROVIDER STATE LICENSE