Basic Information
| Provider Information | |||||||||
| NPI: | 1215908314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 HEATHER DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194752685 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267844 | ||||||||
| FaxNumber: | 7195267894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25019 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.