Basic Information
| Provider Information | |||||||||
| NPI: | 1720123029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | LINWOOD | ||||||||
| MiddleName: | WESTINGHOUSE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7700 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132028660 | ||||||||
| FaxNumber: | 3132028653 | ||||||||
| Practice Location | |||||||||
| Address1: | 2888 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138754200 | ||||||||
| FaxNumber: | 3138755611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 03/31/2014 | ||||||||
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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 | 207R00000X | 4301038485 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5078418 | 05 | MI | MEDICAID |