Provider Demographics
NPI:1508838871
Name:BLACK, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 320
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6896
Practice Address - Country:US
Practice Address - Phone:803-434-6771
Practice Address - Fax:803-434-3855
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86636208000000X
NY232292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026910201OtherUNIVERA HEALTHCARE
1212594OtherIHA
070804000017OtherFIDELIS
NY02577360Medicaid
000527733002OtherBC/BS
NY000527733001OtherBLUE CROSS BLUE SHIELD
00026910202OtherUNIVERA
NY02577360Medicaid