Basic Information
| Provider Information | |||||||||
| NPI: | 1356326136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | BRADFORD | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2777 CARRINGTON ST NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447208163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302440515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 885 S SAWBURG RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446015905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308231112 | ||||||||
| FaxNumber: | 3308231139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 58282 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0738536 | 05 | OH | MEDICAID | 340012867 | 01 | OH | MEDICARE RAILROAD | OTHER |