Basic Information
| Provider Information | |||||||||
| NPI: | 1851474167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | HOUSTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1145 INDIANAPOLIS ROAD | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656538453 | ||||||||
| FaxNumber: | 7656538493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 INDIANAPOLIS ROAD | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656538453 | ||||||||
| FaxNumber: | 7656538493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01024692 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100210870A | 05 | IN | MEDICAID | 1851474167 | 01 | IN | NPI | OTHER | 1790868016 | 01 | IN | GROUP NPI | OTHER | CM7380 | 01 | IN | GROUP PIN | OTHER | 013568191 | 01 | IN | RAILROAD MEDICARE | OTHER |