Provider Demographics
NPI:1588359491
Name:BLACK, STEVENSON JR
Entity type:Individual
Prefix:
First Name:STEVENSON
Middle Name:
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 E 109TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-2767
Mailing Address - Country:US
Mailing Address - Phone:216-326-7889
Mailing Address - Fax:
Practice Address - Street 1:667 E 109TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-2767
Practice Address - Country:US
Practice Address - Phone:216-326-7889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRU776031172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver