Basic Information
| Provider Information | |||||||||
| NPI: | 1700149648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | CHASE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 167 ASHLEY AVE | ||||||||
| Address2: | SUITE 301, MSC 912 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294259120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437920192 | ||||||||
| FaxNumber: | 8437929314 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 RHEA COUNTY HWY | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232855220 | ||||||||
| FaxNumber: | 4232855506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2012 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | LL34886 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 55829 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | T00148A | 01 | TN | MEDICARE PTAN | OTHER | Q029957 | 05 | TN | MEDICAID |