Provider Demographics
NPI:1457764961
Name:BLACK STONE HEALTH PC
Entity Type:Organization
Organization Name:BLACK STONE HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:513-658-8605
Mailing Address - Street 1:2358 NW KINGS BLVD #100
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2358 NW KINGS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-368-5986
Practice Address - Fax:866-624-8745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500683153Medicaid
OR500683153Medicaid