Provider Demographics
NPI:1700149648
Name:BLACK, GARY CHASE (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:CHASE
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 1:167 ASHLEY AVE
Mailing Address - Street 2:SUITE 301, MSC 912
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-9120
Mailing Address - Country:US
Mailing Address - Phone:843-792-0192
Mailing Address - Fax:843-792-9314
Practice Address - Street 1:9400 RHEA COUNTY HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321
Practice Address - Country:US
Practice Address - Phone:423-285-5220
Practice Address - Fax:423-285-5506
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL34886207L00000X
TN55829207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT00148AOtherMEDICARE PTAN
TNQ029957Medicaid