Provider Demographics
NPI:1881681732
Name:BLACK, EARL (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
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 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:46591 ROMEO PLANK RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5742
Practice Address - Country:US
Practice Address - Phone:586-443-4950
Practice Address - Fax:586-443-4980
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301023839208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2880541Medicaid
B43860Medicare UPIN
MI2880541Medicaid