Provider Demographics
NPI:1902074115
Name:DR EVAN G BLACK LLC
Entity Type:Organization
Organization Name:DR EVAN G BLACK LLC
Other - Org Name:ROCKY MOUNTAIN NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-408-5702
Mailing Address - Street 1:PO BOX 95970
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0970
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:5323 WOODROW ST # 120W
Practice Address - Street 2:SUITE 201
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5841
Practice Address - Country:US
Practice Address - Phone:801-261-4711
Practice Address - Fax:801-261-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187597-1205207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT130012929OtherRAILRAOD MEDICARE
UT1902074115Medicaid
UT1902074115Medicaid
UTG02584Medicare UPIN