Provider Demographics
NPI:1124124268
Name:BLACK, HARRY RICHARD (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:RICHARD
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 W ONONDAGA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204
Mailing Address - Country:US
Mailing Address - Phone:315-475-5176
Mailing Address - Fax:315-476-0263
Practice Address - Street 1:659 W ONONDAGA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204
Practice Address - Country:US
Practice Address - Phone:315-475-5176
Practice Address - Fax:315-476-0263
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119574208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0018612OtherGHT
286833OtherUNITED HEALTHCARE
00981OtherBLUE SHIELD
321287OtherMVP
D72337Medicare UPIN
286833OtherUNITED HEALTHCARE