Provider Demographics
NPI:1700802097
Name:YUILL BLACK MD AND MICHAEL R KLETZ MD PC
Entity Type:Organization
Organization Name:YUILL BLACK MD AND MICHAEL R KLETZ MD PC
Other - Org Name:BLACK AND KLETZ MD PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEVOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-790-9675
Mailing Address - Street 1:1420 SPRING HILL RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3006
Mailing Address - Country:US
Mailing Address - Phone:703-790-9722
Mailing Address - Fax:703-893-8666
Practice Address - Street 1:1420 SPRING HILL RD
Practice Address - Street 2:SUITE 350
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3006
Practice Address - Country:US
Practice Address - Phone:703-790-9722
Practice Address - Fax:703-893-8666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACD8485OtherRAILROAD MEDICARE PIN
VAC05588Medicare PIN
VACD8485OtherRAILROAD MEDICARE PIN