Provider Demographics
NPI:1124697958
Name:BLACK, SAMUEL JACOB (MD, PHD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JACOB
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N BROAD ST STE 810
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5189
Mailing Address - Country:US
Mailing Address - Phone:215-707-4085
Mailing Address - Fax:215-707-5978
Practice Address - Street 1:3322 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5185
Practice Address - Country:US
Practice Address - Phone:215-707-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT222514207R00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine