Provider Demographics
NPI:1942716998
Name:BLACK, MIKE A (CEPS, NREMT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:CEPS, NREMT
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 57768
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84157-0768
Mailing Address - Country:US
Mailing Address - Phone:916-217-1584
Mailing Address - Fax:866-722-1584
Practice Address - Street 1:4989 S STATE ST UNIT 57768
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84157-5032
Practice Address - Country:US
Practice Address - Phone:916-217-1584
Practice Address - Fax:866-722-1584
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
E1160515146N00000X
WA60434882246W00000X
DC161255207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No246W00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Cardiology