Provider Demographics
NPI:1902422363
Name:KERTIA BLACK MD BOARD CERTIFIED IN REHABILITATION MEDICINE
Entity Type:Organization
Organization Name:KERTIA BLACK MD BOARD CERTIFIED IN REHABILITATION MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KERTIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-910-7018
Mailing Address - Street 1:27725 RAINBOW CIR
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3238
Mailing Address - Country:US
Mailing Address - Phone:248-910-7018
Mailing Address - Fax:248-557-5409
Practice Address - Street 1:27725 RAINBOW CIR
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-3238
Practice Address - Country:US
Practice Address - Phone:248-910-7018
Practice Address - Fax:248-557-5409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty