Provider Demographics
NPI:1992896310
Name:JERRY N BLACK SURGICAL SUITE
Entity type:Organization
Organization Name:JERRY N BLACK SURGICAL SUITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-472-2100
Mailing Address - Street 1:10 AMALIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201
Mailing Address - Country:US
Mailing Address - Phone:304-472-2100
Mailing Address - Fax:304-472-2118
Practice Address - Street 1:10 AMALIA DRIVE
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201
Practice Address - Country:US
Practice Address - Phone:304-472-2100
Practice Address - Fax:304-472-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1445304OtherUMWA
WV0096696001Medicaid
WV0096696001Medicaid