Basic Information
| Provider Information | |||||||||
| NPI: | 1942264700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ARIC | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 ENTERPRISE BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644540888 | ||||||||
| FaxNumber: | 8644541130 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 GROVE RD | ||||||||
| Address2: | ANESTHESIA DEPT 2ND FLOOR | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296055611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644557111 | ||||||||
| FaxNumber: | 8644556441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APRN1269 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 20013584 | 01 | SC | SELECT HEALTH | OTHER | AN0906 | 05 | SC | MEDICAID |