Provider Demographics
NPI:1013282169
Name:BLACK, CHRISTINE E (MD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:E
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-2408
Practice Address - Street 1:500 S 11TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4878
Practice Address - Country:US
Practice Address - Phone:208-232-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056998207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology