Basic Information
| Provider Information | |||||||||
| NPI: | 1770786667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 495 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414766644 | ||||||||
| FaxNumber: | 5414725673 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414766644 | ||||||||
| FaxNumber: | 5414725673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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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 | 208000000X | MD 170104 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics | 202C00000X | 036113715 | IL | N | Allopathic & Osteopathic Physicians | Independent Medical Examiner | 208000000X | 036113715 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 500680833 | 05 | OR | MEDICAID | 036113715 | 05 | IL | MEDICAID |