Provider Demographics
NPI:1922465343
Name:BLACK, KARL
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:
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 1:601 VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-3342
Mailing Address - Country:US
Mailing Address - Phone:205-381-2683
Mailing Address - Fax:
Practice Address - Street 1:601 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209-3342
Practice Address - Country:US
Practice Address - Phone:205-381-2683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5300003647709Medicaid