Provider Demographics
NPI:1972008373
Name:BLACK, LOREN ORION (MD MBA)
Entity type:Individual
Prefix:DR
First Name:LOREN
Middle Name:ORION
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6165 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8613
Practice Address - Country:US
Practice Address - Phone:208-302-3900
Practice Address - Fax:208-302-3955
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61416009207X00000X, 207XX0801X
IDM-17771207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma