Basic Information
| Provider Information | |||||||||
| NPI: | 1669446167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12598 PINK MYRTLE CT | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334737127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542886500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1613 HARRISON PKWY | ||||||||
| Address2: | #200 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548382371 | ||||||||
| FaxNumber: | 9518511758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME81928 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 260780800 | 05 | FL | MEDICAID |