Provider Demographics
NPI:1174609754
Name:BLACK, TINA M (DO)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1493
Mailing Address - Country:US
Mailing Address - Phone:440-899-0900
Mailing Address - Fax:440-899-0976
Practice Address - Street 1:850 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1493
Practice Address - Country:US
Practice Address - Phone:440-899-0900
Practice Address - Fax:440-899-0976
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005618207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0936116Medicaid
OH740121OtherBCHP
OHP00338796OtherCARERR
OH000000380935OtherANTHEM BC/BS
OH378646OtherWELLCARE
OH341542312098OtherCARESOURCE
OH740121OtherBCHP
OH0936116Medicaid