Basic Information
| Provider Information | |||||||||
| NPI: | 1013282169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S 11TH AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327862 | ||||||||
| FaxNumber: | 2082322408 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S 11TH AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082323655 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | DR.0056998 | CO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.