Provider Demographics
NPI:1851474167
Name:BLACK, THOMAS HOUSTON III (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HOUSTON
Last Name:BLACK
Suffix:III
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 1:1145 INDIANAPOLIS ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135
Mailing Address - Country:US
Mailing Address - Phone:765-653-8453
Mailing Address - Fax:765-653-8493
Practice Address - Street 1:1145 INDIANAPOLIS ROAD
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135
Practice Address - Country:US
Practice Address - Phone:765-653-8453
Practice Address - Fax:765-653-8493
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100210870AMedicaid
IN1851474167OtherNPI
IN1790868016OtherGROUP NPI
INCM7380OtherGROUP PIN
IN013568191OtherRAILROAD MEDICARE
IN1790868016OtherGROUP NPI
IN013568191OtherRAILROAD MEDICARE
IN100210870AMedicaid