Provider Demographics
NPI:1932859956
Name:BLACK, MILES HENRY (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:HENRY
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-2420
Mailing Address - Country:US
Mailing Address - Phone:908-578-5520
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-4829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program