Provider Demographics
NPI:1134883143
Name:BLACK CREEK MEDICAL LLC
Entity type:Organization
Organization Name:BLACK CREEK MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SALERNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-376-6100
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-0648
Mailing Address - Country:US
Mailing Address - Phone:914-376-6100
Mailing Address - Fax:914-470-5056
Practice Address - Street 1:46 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1864
Practice Address - Country:US
Practice Address - Phone:914-376-6100
Practice Address - Fax:914-470-5056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty