Provider Demographics
NPI:1881056646
Name:BLACK, KATHERINE (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 FORSYTH ST STE 2E
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8631
Mailing Address - Country:US
Mailing Address - Phone:478-633-7330
Mailing Address - Fax:478-633-7360
Practice Address - Street 1:1062 FORSYTH ST STE 2E
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8631
Practice Address - Country:US
Practice Address - Phone:478-633-7330
Practice Address - Fax:478-633-7360
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92412208000000X, 2080P0206X
TN59619208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics