Provider Demographics
NPI:1316908791
Name:BLACK, STEPHANIE R (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 239D
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8018
Mailing Address - Country:US
Mailing Address - Phone:847-759-1560
Mailing Address - Fax:847-803-1006
Practice Address - Street 1:600 S PAULINA ST
Practice Address - Street 2:SUITE 143
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3806
Practice Address - Country:US
Practice Address - Phone:312-942-2061
Practice Address - Fax:312-942-2184
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-097246207R00000X
IL036097246207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL440003692OtherRR MEDICARE
IL036097246Medicaid