Provider Demographics
NPI:1801853593
Name:BLACK, BARRY G (CRNA)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:G
Last Name:BLACK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 FLINT RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-6031
Mailing Address - Country:US
Mailing Address - Phone:256-353-0626
Mailing Address - Fax:256-350-2609
Practice Address - Street 1:1122 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3361
Practice Address - Country:US
Practice Address - Phone:256-560-2890
Practice Address - Fax:256-350-2609
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-066229367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
51526755OtherBCBS OF AL PIN
51526755OtherBCBS OF AL PIN