Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 4351048510 | MI |
NPI | 1083289730 |
---|---|
Provider Name | Dr. Jordan Black |
First Address | Royal Oak, MI 48073-6712 |
Second Address | Royal Oak, MI 48073-6710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2021 |
Last Update Date | 25/05/2021 |