Provider Demographics
NPI:1508032194
Name:BLACK, COLLEEN ROCHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:ROCHELLE
Last Name:BLACK
Suffix:
Gender:F
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:844-266-8268
Mailing Address - Fax:
Practice Address - Street 1:6555 KEE LN STE 200
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-7463
Practice Address - Country:US
Practice Address - Phone:704-316-6140
Practice Address - Fax:704-316-6141
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00927208000000X
VA0116017287208000000X
DCMD037639208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916285Medicaid