Provider Demographics
NPI:1396777991
Name:BLACK, LINDA S (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:S
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 UPPERGATE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322
Mailing Address - Country:US
Mailing Address - Phone:404-727-3360
Mailing Address - Fax:404-727-3237
Practice Address - Street 1:2015 UPPER GATE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1014
Practice Address - Country:US
Practice Address - Phone:404-727-3360
Practice Address - Fax:404-727-3237
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0410792080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA499210OtherBCBS
F06866Medicare UPIN