Basic Information
| Provider Information | |||||||||
| NPI: | 1396700613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 PRYTANIA ST | ||||||||
| Address2: | STE 35 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701153628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978315 | ||||||||
| FaxNumber: | 5048919862 | ||||||||
| Practice Location | |||||||||
| Address1: | 519 METAIRIE RD | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700054311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043249024 | ||||||||
| FaxNumber: | 5043736807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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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 | 207RH0003X | 05701R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1326313 | 05 | LA | MEDICAID |