Provider Demographics
NPI:1891010567
Name:BLACK, MATTHEW CRITTENDEN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CRITTENDEN
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0325
Mailing Address - Fax:
Practice Address - Street 1:200 LOTHROP ST.
Practice Address - Street 2:C800
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213
Practice Address - Country:US
Practice Address - Phone:412-647-7555
Practice Address - Fax:412-647-3710
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48212208G00000X
PAMD464171208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100177690Medicaid