Provider Demographics
NPI:1316254139
Name:BLACK, ASHLEY GALE (DO)
Entity type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:GALE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W TALCOTT AVE STE 542
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3716
Mailing Address - Country:US
Mailing Address - Phone:773-631-2180
Mailing Address - Fax:773-631-5947
Practice Address - Street 1:7447 W TALCOTT AVE STE 542
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3716
Practice Address - Country:US
Practice Address - Phone:773-631-2180
Practice Address - Fax:773-631-5947
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.131207207R00000X
IL036131207207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036131207Medicaid
F400108271OtherPTAN