Provider Demographics
NPI:1841215316
Name:BLACK, HENRY RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:RICHARD
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 1:15 W 81ST ST
Mailing Address - Street 2:APT. 3J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6022
Mailing Address - Country:US
Mailing Address - Phone:212-924-0054
Mailing Address - Fax:
Practice Address - Street 1:15 W 81ST ST
Practice Address - Street 2:APT. 3J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6022
Practice Address - Country:US
Practice Address - Phone:212-924-0054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242954207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL62204Medicare ID - Type Unspecified
ILD88748Medicare UPIN