Basic Information
| Provider Information | |||||||||
| NPI: | 1508838871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 MAIN ST FL 5 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163230034 | ||||||||
| FaxNumber: | 7163230292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MAIN ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163230034 | ||||||||
| FaxNumber: | 7163230292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 86636 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 232292 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1212594 | 01 | IHA | OTHER | 000527733002 | 01 | BC/BS | OTHER | 00026910202 | 01 | UNIVERA | OTHER | 02577360 | 05 | NY | MEDICAID | 070804000017 | 01 | FIDELIS | OTHER | 000527733001 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 00026910201 | 01 | NY | UNIVERA HEALTHCARE | OTHER |