Provider Demographics
NPI:1952442832
Name:CHARLES L. BLACK JR MD SURGICAL CLINIC CORP
Entity Type:Organization
Organization Name:CHARLES L. BLACK JR MD SURGICAL CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-0166
Mailing Address - Street 1:1534 ELIZABETH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4516
Mailing Address - Country:US
Mailing Address - Phone:318-221-0166
Mailing Address - Fax:
Practice Address - Street 1:1534 ELIZABETH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4516
Practice Address - Country:US
Practice Address - Phone:318-221-0166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011576208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1169838Medicaid
LA5CJ93Medicare ID - Type Unspecified
LA1169838Medicaid