Provider Demographics
NPI:1457398422
Name:BLACK, COREY (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
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 1:13700 ST FRANCIS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-3222
Mailing Address - Country:US
Mailing Address - Phone:804-594-7300
Mailing Address - Fax:804-594-7410
Practice Address - Street 1:13700 ST FRANCIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3222
Practice Address - Country:US
Practice Address - Phone:804-594-7300
Practice Address - Fax:804-594-7410
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49283-020207R00000X
IL036103860208M00000X, 207R00000X
VA0101271663207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101271663OtherSTATE LICENSE
IL036103860OtherSTATE LICENSE
WI34726800Medicaid