Provider Demographics
NPI:1053301887
Name:BLACK, ROBERT E (ATC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:BLACK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 W WINTERSWEET CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-1827
Mailing Address - Country:US
Mailing Address - Phone:812-345-3343
Mailing Address - Fax:
Practice Address - Street 1:1001 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1590
Practice Address - Country:US
Practice Address - Phone:812-856-2225
Practice Address - Fax:812-855-1810
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000062A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer