Provider Demographics
NPI:1538596309
Name:CHAD BLACK MD, LLC
Entity type:Organization
Organization Name:CHAD BLACK MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-287-6955
Mailing Address - Street 1:610 SYCAMORE STREET SUITE 130
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 SYCAMORE STREET SUITE 130
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747
Practice Address - Country:US
Practice Address - Phone:321-287-6955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOWN CENTER FAMILY MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty