Provider Demographics
NPI:1356407902
Name:BLACK, CHARLES BRAD (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRAD
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2056
Mailing Address - Country:US
Mailing Address - Phone:406-293-9274
Mailing Address - Fax:406-293-9280
Practice Address - Street 1:214 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2056
Practice Address - Country:US
Practice Address - Phone:406-293-9274
Practice Address - Fax:406-293-9280
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT92298OtherBLUE CROSS BLUE SHIELD MT
MT00056940Medicaid
MT92298OtherBLUE CROSS BLUE SHIELD MT
MT000083020Medicare ID - Type Unspecified