Provider Demographics
NPI:1922006485
Name:BLACK, WILLIAM R (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
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 1:825 W HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2725
Mailing Address - Country:US
Mailing Address - Phone:704-636-5542
Mailing Address - Fax:704-636-5142
Practice Address - Street 1:825 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2725
Practice Address - Country:US
Practice Address - Phone:704-636-5542
Practice Address - Fax:704-636-5142
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19313207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC15968OtherBC/BS
NC408113860OtherRRMEDICARE
NC8915968Medicaid
NC408113860OtherRRMEDICARE
NC202084AMedicare PIN