Provider Demographics
NPI:1740436781
Name:BLACK, JUSTIN RAY (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RAY
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 1:3546 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2243
Mailing Address - Country:US
Mailing Address - Phone:708-922-9299
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC4028
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-702-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121182207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology