Provider Demographics
NPI:1972739001
Name:BLACK, MICHELLE T (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:T
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 E GEDDES AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3800
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:720-874-4462
Practice Address - Street 1:10700 E GEDDES AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-3800
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:720-874-4462
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORLL18706207R00000X
HIMD189812085R0202X
CA1134662085R0202X
NE297762085R0202X
KS04-396042085R0202X
CO579452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56135157Medicaid
CO550236YQ33Medicare PIN
CO56135157Medicaid
CO550236YQPGMedicare PIN
NENA2517082Medicare PIN
KS111257092Medicare PIN
NENA1214104Medicare PIN
CO550236ZLJ3Medicare PIN
CO550236YQN9Medicare PIN
KSKA3249083Medicare PIN