Provider Demographics
NPI:1831198084
Name:BLACK, HAROLD MICAGAH (CRNA)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:MICAGAH
Last Name:BLACK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 37090
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3090
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-295-9369
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-391-3129
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024070513367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139180OtherANTHEM
VA1831198084Medicaid
VA298077OtherAMERIGROUP
DCK142-0002OtherCAREFIRST
DC006341F89Medicare PIN
VA139180OtherANTHEM
VA430069092Medicare ID - Type UnspecifiedRAILROAD
VA1831198084Medicaid