Provider Demographics
NPI:1134577067
Name:BLACK, DANE ALEXANDER (DO)
Entity type:Individual
Prefix:DR
First Name:DANE
Middle Name:ALEXANDER
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-4000
Mailing Address - Fax:
Practice Address - Street 1:55 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1187
Practice Address - Country:US
Practice Address - Phone:740-779-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.007899390200000X
OH34.013915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program