Basic Information
| Provider Information | |||||||||
| NPI: | 1710184908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAST PENN SQUARE | ||||||||
| Address2: | THE WANAMAKER BUILDING, 9TH FLOOR, N. | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 34TH STREET & CIVIC CENTER BLVD | ||||||||
| Address2: | SUITE 9329 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901858 | ||||||||
| FaxNumber: | 2155901415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | MD443506 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 208000000X | MT191494 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 254874EJL | 01 | PA | MEDICARE PTAN | OTHER | 1027597410001 | 05 | PA | MEDICAID |