Provider Demographics
NPI:1215047626
Name:BLACK, HOWARD MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:MATTHEW
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 1:102 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:ROARING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:16673-1210
Mailing Address - Country:US
Mailing Address - Phone:814-224-2215
Mailing Address - Fax:814-224-2011
Practice Address - Street 1:102 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673-1210
Practice Address - Country:US
Practice Address - Phone:814-224-2215
Practice Address - Fax:814-224-2011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039083E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01294853Medicaid
PABL060982Medicare ID - Type Unspecified
PA01294853Medicaid