Provider Demographics
NPI:1053424234
Name:BLACK, CHARLES GLENN (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:GLENN
Last Name:BLACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 COLONIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-4417
Mailing Address - Country:US
Mailing Address - Phone:410-570-1446
Mailing Address - Fax:410-721-7580
Practice Address - Street 1:1231 COLONIAL PARK DR
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-4417
Practice Address - Country:US
Practice Address - Phone:410-570-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5120OtherGHMSI/BLUECHOICE
701076OtherACN
18GMMAOtherBCBS OF MARYLAND
126798YT8Medicare PIN