Provider Demographics
NPI:1720075773
Name:BLACK, GRETCHEN ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 HUTTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-4526
Mailing Address - Country:US
Mailing Address - Phone:913-299-3700
Mailing Address - Fax:
Practice Address - Street 1:2040 HUTTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-4526
Practice Address - Country:US
Practice Address - Phone:913-299-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003014690208000000X
KS05-33433208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics